Every finding on record at Golden Palms Rehabilitation and Retirement

Based on interviews and record review, the facility failed to provide pharmaceutical services that included the accurate acquiring and receiving of all drugs and biologicals to meet the needs of each resident for 1 (Resident #1) of 3 residents. The facility failed to ensure that Resident #1 received his Theophylline medication on 4/25/26 as prescribed on the medication reconciliation physician orders signed and dated 4/24/26. The deficient practice could result in exacerbation of the resident's condition and disease process. Findings included: Record review of Resident #1's face sheet, dated 05/11/26, reflected the resident was a [AGE] year-old male, with an admission date of 4/24/26. Resident #1 had diagnoses of bronchiectasis (lung condition where the airways become permanently damaged, widened, and scarred) with (acute (sudden onset or severe)) exacerbation, dyspnea (shortness of breath or difficulty breathing), acute (sudden onset or severe) respiratory failure, hypercapnia (abnormally elevated level of carbon dioxide in the bloodstream), and chronic obstructive pulmonary disease (a progressive, irreversible lung condition that restricts airflow, making it hard to breathe) with (acute (sudden onset or severe)) lower respiratory infection. Record review of Resident #1's comprehensive MDS assessment dated [DATE], reflected as follows:Resident #1 had a BIMS score of 14 indicating cognitively intact. Section J11 Shortness of Breath (dyspnea) indicated shortness of breath or trouble breathing when lying flat. Section O - Special Treatments, Procedures, and Programs indicated on oxygen therapy and receiving respiratory therapy. Record review of Resident #1's undated care plan reflected the following:Has risk for altered respiratory status/Difficulty Breathing r/t Dx's Bronchiectasis, acute respiratory failure, COPD, pulmonary edema, pulmonary hypertension. Date Initiated: 04/27/2026 Revision on: 05/07/2026. Administer medication/puffers as ordered. Monitor for effectiveness and side effects. Date Initiated: 04/27/2026.Record review of a physician order on EMR for Resident #1 dated 4/26/26 reflected Theophylline ER Capsule Extended Release 24 Hour 100 MG Give 4 capsule by mouth one time a day for Shortness of Breath ordered date 4/26/26 and start date 4/27/26. Record review of a Medication Reconciliation for Resident #1 from hospital, signed by admitting MD and dated 4/24/26 reflected the following:Continue theophylline 100 mg/24 hours oral capsule extended release 400 mg oral daily - last administered on 4/24/26 at 9:01 am. Record review of written documentation dated 4/24/26 to 5/11/26 provided by Resident #1's family member reflected last dose of Theophylline given at hospital on 4/24/26 at 5:00 p.m. and Resident #1 was admitted to the nursing facility around 7:30 p.m. Record review of Progress Notes dated 4/27/26 reflected that RN C received Theophylline 24 ER 200 mg capsule from family member. 109 capsules inside bottle. Record review of a physician order on EMR for Resident #1 dated 4/27/26 reflected Theophylline ER Capsule Extended Release 24 Hour 200 MG Give 2 capsule by mouth two times a day for Shortness of Breath ordered date 4/26/26 and start date 4/27/26.Record review of Resident #1's Medication Administration Record for April 2026 revealed Theophylline ER Capsule Extended Release 24 Hour 100 MG Give 2 capsule by mouth two times a day for Shortness of Breath -Order Date- 04/27/2026 -D/C Date- 04/30/2026. Theophylline shown administered from 4/27/26 to 4/30/26.In an interview on 5/12/26 at 8:50 a.m., Resident #1 said when he first arrived at the facility Friday, 4/24/26, they were not ready for him. He said the facility did not have the Theophylline he was prescribed available. Resident #1 said they provided both doses of Theophylline medication at the hospital on 4/24/26 prior to arriving at the facility. Resident #1 said he recalled not taking the Theophylline medication the next day, Saturday, 4/25/26. Resident #1 said his family member brought his Theophylline medication from home and he began taking the medication as prescribed, but they were informed by the facility he could not do that. The facility informed Resident #1 they must obtain approval and orders from his MD, then the facility would administer the medication to him. Resident #1 said the Theophylline medication was important because it helped prevent shortness of breath.In a telephone interview on 5/12/26 at 11:00 a.m., LVN A said the only concern regarding Resident #1's Theophylline was that the doctor ordered it as a 400 mg tablet once a day. LVN A said the DON had her call Resident #1's doctor, and he said it was fine and ok for him to take the tablet once daily versus two in the morning and two at night, as long as it totaled 400 mg. LVN A said they set up an appointment for Resident #1 to talk to his doctor, so he could inform Resident #1 there was no difference because it was an extended release. LVN A said they did not always have all the medications available at the facility upon a resident's admission. LVN A said they would ask residents if they had their own medications available to use them until they obtain the medications from the pharmacy. LVN A said Resident #1 began taking his own medications because he wanted to take his own medications. LVN A said the pharmacy sent his medication the following afternoon. LVN A said the medications might have come in after 10 pm and at that time he was taking his own medications, so they could not give both. LVN A said she did not work Saturday 4/25/26 and Sunday 4/26/26, but she felt everything regarding Resident #1's medications upon admission was taken care of. LVN A said there would not be a negative effect because the resident took his own medication over the weekend. In an interview on 5/12/26 at 11:53 a.m., LVN B said for Resident #1, she did not recall what medications he had on his medication reconciliation list or if there was a concern with the medication Theophylline. LVN B did not recall if she worked with Resident #1 over the weekend. LVN B said she did not recall hearing a medication was brought in from home by Resident # 1's family member or that family member and Resident #1 administered a medication on their own. LVN B said when she administered medications, she let the resident know what medications she was going to administer. LVN B said she always compared the blister packet with the MAR and orders, which was how she ensured the right patient, the right medication, the right dose, the right route, and the right time. LVN B said they received in-services about medication administration and entering orders. LVN B said she did not recall if she worked the weekend with Resident #1. LVN B said she did not recall any concerns that Resident #1 did not take a dose of his Theophylline medication over the weekend, so there would be no adverse effects. In an interview on 5/12/26 at 12:30 p.m. RN C said when a resident was admitted to the facility, they receive the admission information from the receiving entity prior to the resident's arrival. RN C said when they received report, the discharging entity would inform them when the resident was ready to be discharged to the facility. RN C said usually when a resident was discharged from the hospital they arrived during the night shift. RN C said if the facility did not have a medication for a resident, they would get the medication from the facility's Pyxis (automated medication dispensing system) until the pharmacy could provide the medication. RN C said she was not sure if Theophylline was a medication that was usually stocked in Pyxis or not. RN C said she remembered giving Resident #1 his own medication from home when she obtained the order from the MD. Record review of progress note indicated medication from home and MD order received.RN C said they usually received medication orders from the pharmacy that same day, even on the weekends because the pharmacy's cut off times were 10:00 or 11:00 p.m. RN C said they received medications from the pharmacy every single day. RN C said she remembered they were waiting for the pharmacy to send the Theophylline for Resident #1. RN C said she was not sure if the wait was due to any questions with orders received. RN C said she did not know anything more about Resident #1's medications. RN C said Resident #1 never disclosed to her that he did not receive his Theophylline medication over the weekend. RN C said she did not know if Resident #1 took his own medication on the weekend without staff knowing. RN C said if the resident missed a dose of Theophylline, it could cause an exacerbation of shortness of breath, but she did not recall any exacerbations of shortness of breath while she had worked with him. RN C said when she administered medications, she let the resident know it was time to administer their medications. She would verify the information on the MAR with the orders and would verify the right patient, the right medication, the right time, the right dose, and the right route. RN C said she would then prepare the medication accordingly and administer to the resident explaining what it was for.In a telephone interview on 5/13/26 at 11:10 a.m. The Pharmacist said Resident #1's prescription for Theophylline came into the pharmacy on 4/24/26 after 7:00 p.m. and they had a cut off time from their wholesaler. The Pharmacist said their wholesalers were also not available the weekend, so the medication Theophylline came into the pharmacy Monday morning. The pharmacist said as per the delivery slip, Theophylline 400 mg 1 tablet a day was ordered for Resident #1 on 4/24/26 and it was delivered to the facility on 4/28/26 at 6:55 pm. The Pharmacist said they normally delivered medications to the facility twice a day. The pharmacist said the medication Theophylline was not a common drug placed in the e-kit (emergency kit) because it was not considered emergent. The pharmacist checked their report and informed me Theophylline was not available in the facility's e-kit.In a telephone interview on 5/13/26 at 11:56 a.m. the MD said Resident #1 was receiving 200 mg Theophylline twice a day at home. The MD said there was a problem with the Theophylline not going to be delivered on time, so since the family member had the Theophylline medication at home, they gave Resident #1 his own medication on the weekend. The MD said on Monday, 4/27/26 the pharmacy delivered the Theophylline tablet 400 mg one time a day. The MD said the dose was the same, but the family member had questions about it, so he explained it. The MD said he requested Theophylline levels to ensure everything was fine and were pending the results. The MD said he was informed by nursing staff at the facility that the resident received all his doses of Theophylline during the weekend due to the wife bringing the medication from home, so he was not aware if Resident #1 missing any doses. The MD said if Resident #1 did miss one day of the Theophylline medication, there would be no implications or adverse effects.In an interview on 5/13/26 at 4:30 p.m., the DON said the nurses knew when there was no medication available for a resident, they informed the family to see if the family could bring their own medication so there was no delay. The DON said she cannot 100% say that was the case with Resident #1. The DON said after she reviewed all the information, it appeared as if Resident #1 did not receive his Theophylline on 4/25/26. The DON said if Theophylline were given for prevention of shortness of breath, there could potentially be shortness of breath if Resident #1 was not given the medication. The DON said Resident #1 absolutely should not have missed any dose of the medication. The DON said she contacted the pharmacist and provided them with her contact information so they could contact her if there was a medication they did not have. Prior to that, when medications were signed in, the nurses would sign off, and they placed the medication on the requisition form. The DON said it would be the responsibility of the next shift nurse to ensure all medications were received, contacted pharmacy to get status update, and if the medication was not going to come in during their shift, they needed to notify the MD so he could decide on a plan B. The DON said nurses should have also notified their DON.In an interview on 5/13/26 at 5:19 p.m., the Operations Manager said after review of the documentation, it seemed the medication Theophylline was not given on 4/25/26. The Operations Manager said there should not have been a missed dose of the Theophylline.Record review of the undated Medication Administration - Oral Policy / Procedure revealed: Policy:It is the policy of this facility to accurately prepare. Administer and document oral medications.13. Any irregularity in pouring or administering must be reported to the doctor.15. All medication administration will be documented on medication administration record.Record review of the Pharmacy Services Policy / Procedure revealed: PolicyIt is the policy of this facility to employ or obtain the services of a licensed pharmacist to provide consultation on all aspects of pharmacy services in the facility, establish a system of records of receipt and disposition of all controlled drugs is maintained and periodically reconciled, to enable accurate reconciliation. PurposeThe pharmacist is responsible for helping the facility obtain and maintain timely and appropriate pharmaceutical services that support resident's healthcare needs, that are consistent with current standards of practice, and that meet state and federal requirements.6. Strive to assure that medications are requested, received, and administered in a timely manner as ordered by the physician.

Based on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete, accurately documented, readily accessible, and systematically organized for 1 (Resident #1) of 3 residents reviewed for accurate medical records. The facility failed to accurately document the administration of Theophylline on Resident #1's MAR on 4/27/26. This deficient practice could place residents at risk of having incomplete or inaccurate records and residents receiving delayed or inadequate treatment or care.The findings include:Record review of Resident #1's face sheet, dated 05/11/26, reflected the resident was a [AGE] year-old male, with an admission date of 4/24/26. Resident #1 had diagnoses of bronchiectasis (lung condition where the airways become permanently damaged, widened, and scarred) with (acute (sudden onset or severe)) exacerbation, dyspnea (shortness of breath or difficulty breathing), acute (sudden onset or severe) respiratory failure, hypercapnia (abnormally elevated level of carbon dioxide in the bloodstream), and chronic obstructive pulmonary disease (a progressive, irreversible lung condition that restricts airflow, making it hard to breathe) with (acute (sudden onset or severe)) lower respiratory infection. Record review of Resident #1's comprehensive MDS assessment dated [DATE], reflected as follows:Resident #1 had a BIMS score of 14 indicating cognitively intact. Section J11 Shortness of Breath (dyspnea) indicated shortness of breath or trouble breathing when lying flat. Section O - Special Treatments, Procedures, and Programs indicated on oxygen therapy and receiving respiratory therapy. Record review of Resident #1's undated care plan reflected the following:Has risk for altered respiratory status/Difficulty Breathing r/t Dx's Bronchiectasis, acute respiratory failure, COPD, pulmonary edema, pulmonary hypertension. Date Initiated: 04/27/2026 Revision on: 05/07/2026. Administer medication/puffers as ordered. Monitor for effectiveness and side effects. Date Initiated: 04/27/2026.Record review of a physician order on EMR for Resident #1 dated 4/26/26 reflected Theophylline ER Capsule Extended Release 24 Hour 100 MG Give 4 capsule by mouth one time a day for Shortness of Breath ordered date 4/26/26 and start date 4/27/26.Record review of a physician order on EMR for Resident #1 dated 4/27/26 reflected Theophylline ER Capsule Extended Release 24 Hour 200 MG Give 2 capsule by mouth two times a day for Shortness of Breath ordered date 4/26/26 and start date 4/27/26.Record review of Resident #1's Medication Administration Record for April 2026 revealed Theophylline ER Capsule Extended Release 24 Hour 100 MG Give 4 capsule by mouth one time a day for Shortness of Breath -Order Date- 04/26/2026 6:27 p.m. -D/C Date- 04/27/2026 3:17 p.m. Theophylline administered on 4/27/26. Record review of Resident #1's Medication Administration Record for April 202026. Theophylline ER Capsule Extended Release 24 Hour 100 MG Give 2 capsule by mouth two times a day for Shortness of Breath -Order Date- 04/27/2026 3:17 p.m. -D/C Date- 04/30/2026 5:41 p.m. Theophylline administered on 4/27/26 to 4/30/26.In an interview on 5/12/26 at 12:30 p.m. RN C said RN said when administering medications, she will let the resident know it was time to administer their medications. She will verify the information on the MAR with the orders and will verify the right patient, right medication, right time, right dose, and right route. RN Said she would then prepare the medication accordingly and give to resident explaining what it was for. RN C said she remembered they were waiting for the pharmacy to send the Theophylline medication for Resident #1. RN C said she was not sure if the wait was due to any questions with orders received. RN C said she remembered giving Resident #1 his own medication from home when she obtained the order from the MD. Record review of progress note indicated medication from home and MD order received. RN C said she recalls only giving him 2 capsules in the morning. RN C said she recalled Resident #1 told her that was what he received at the hospital. RN C said she knew he was going to receive another dose in the evening. RN C said she was not sure why it would show marked as administered 4 capsules in the morning on the MAR. RN C said she knew Resident was being administered his home medication of Theophylline of 2 capsules (100 mg each capsule) twice a day. RN C said she never administered Resident #1 4 capsules. RN C said placing inaccurate documentation could cause residents to receive inaccurate medication dosing.In an interview on 5/13/26 at 4:30 p.m., The DON said after she reviewed the MAR and the orders, it looked like RN C DC'd the order for Theophylline 400 mg once a day and it just did not delete. The DON said it was obvious that RN C knew and administered only 2 capsules of Theophylline because RN C was the one who received and input the orders from the MD. The DON said at times when an old order was removed, it just stayed in the EMR. The DON said she doesn't know why that happened. The DON said RN C may have accidentally deleted the order after she had already entered her signature on the old order. The DON said she was certain RNC would not give Resident #1 4 capsules instead of 2. The DON said RN C should have accurately verified the orders against the MAR. If not, it would reflect inaccurate medication dosing.Record review of the Physician Orders Policy / Procedure review date of 8/2022 revealed: .Procedures:6. Medication, treatment or related procedure orders are transcribed in the eMAR, eTAR accordingly.Record review of the undated Medication Administration - Oral Policy / Procedure revealed: Policy:It is the policy of this facility to accurately prepare. Administer and document oral medications.13. Any irregularity in pouring or administering must be reported to the doctor.15. All medication administration will be documented on medication administration record.

Based on observations, interviews, and record review, the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 8 of 19 resident A-Beds (1201-A, 1202-A, 1205-A, 1207-A, 1209-A, 1211-A, 1213-A, and 1215-A) reviewed for environment.The facility failed to ensure resident rooms 1201-A, 1202-A, 1205-A, 1207-A, 1209-A, 1211-A, 1213-A, and 1215-A had a covering or door on their closets. This deficient practice could place residents at risk of their personal belongings being seen, touched, or stolen. The findings were:Observations of the facility from 04/13/26-04/15/26, beginning at 9:38 am, revealed rooms 1201-A, 1202-A, 1205-A, 1207-A, 1209-A, 1211-A, 1213-A, and 1215-A had no covering or door on their closets. The A-bed closets were located in the rooms adjacent to the hallway door. Anyone entering the rooms could easily rub against the exposed clothing. Anyone passing by the rooms in the hallway could easily touch or remove the exposed clothing. In an interview with Resident #19 on 04/13/26 at 8:50 am, she said she did not like her closet open because she did not want people to be looking at her things.In an interview with the OM on 04/14/26 at 1:30 pm, she said the open closet doors had been that way for a while. She said she was not sure how long the A-Bed closets had been without doors, but maybe 2-3 months. She said contractors were ordering doors to be placed on the open closets. She said she had not considered the residents who owned the clothes to be at risk for infection control, since the open closets were adjacent to the hallway door; anyone could pass by, touch the clothes, or even take them. She said she would have the contractors place temporary curtains until solid doors were placed. In an interview with the DON on 04/14/26 at 3:24 pm, she said she had worked at the facility since February 2025. She said the A-Bed closets had never been covered, and she did not know why. She said it never crossed her mind that the clothing could be contaminated or removed by someone passing by in the main hallway. She said the residents could get sick from cross-contamination, and they would be at high risk because of the potential organism and because the aged residents were already compromised. She said the A- Bed closets were getting durable curtains hung as of today. She said the building was undergoing renovation beginning around 6 months ago. In an interview with the ADM on 04/15/26 at 11:00 am, she said all the A-Beds in the 1200 hall had no curtains or doors because they had been taken down in preparation for reconstruction. She said the rooms had been painted and did not know why all the curtains were removed at the same time. She said the contractors should have taken them down as needed. She said she had worked at the facility since July 2024, and the A-Beds had curtains then. She said the building was bought in 2019, and the 1200-hall was like that (meaning the A-Beds had curtains covering the residents' clothes in their closets). She said she did not know why the closets had doors on one side (b) and curtains on the other (a). In an interview with LS and MS on 04/15/26 at 1:30 pm, LS said she worked at the facility for 4 years. She said the curtains on the A-Bed resident rooms had been removed about 2-3 months ago when reconstruction started. MS said at first, there were plastic accordion-type sliding doors on the A-Bed closets, and 3 years ago, the administrator at the time had them removed and replaced with curtains and rods. They both said no one questioned it when the resident's clothing was exposed. LS said none of the residents complained to her about their closets after the curtains were taken down. MS said there was an order placed for wooden closet doors for the A-Beds to match the B-Bed closets. There were no contractors available during the survey. The ADM provided an invoice/sales receipt # 20847 dated 02/25/26 that indicated 12, 6x9 ft. panels (doors) had been ordered and was stamped paid.The facility was unable to provide a policy for a homelike environment.

Based on record reviews and interviews, the facility failed to send a copy of the residents' discharge notice, prior to discharge, to the representative of the Office of State Long-Term Care (LTC) Ombudsman of the residents' transfer or discharge and the reasons for the move for 2 of 2 (Resident #1 and Resident #53) reviewed for residents' discharge.1. Resident #1 was discharged to the hospital on 1/11/26 without a notice to the LTC state ombudsman.2. Resident #53 was discharged home on [DATE] without a notice to the LTC state ombudsman.These failures could place residents at risk of not knowing their rights and receiving the services of the state LTC Ombudsman.Findings were:1. Record review of Resident #1's admission record dated 4/14/26 revealed Resident #1 was a [AGE] year-old female with diagnoses of urinary tract infection, muscle weakness, cirrhosis of the liver, type II diabetes mellitus with hyperglycemia (high blood sugar levels), morbid (severe) obesity, hypertension (high blood pressure) and sepsis (life threatening infection which can damage tissues and organs throughout the body). Record review of Resident #1's MDS dated [DATE] revealed a BIMS score of 14 indicating intact cognition. Section Q indicates Resident #1's discharge goal is to discharge to the community and active discharge planning is already occurring for Resident #1. Record review of Resident #1's care plan reflects Resident #1 wishes to return/be discharged home. Date initiated: 01/06/2026. Establish a pre-discharge plan with the resident, family/caregivers and evaluate progress and revise plan as needed. Date Initiated: 01/06/2026. Record review of Resident #1's electronic medical record revealed a progress note dated 1/11/26 stating Resident #1 had been discharged to the hospital. Record review of Resident #1's electronic medical record from 1/5/26 to 4/15/26 revealed no evidence of notice given to the LTC Ombudsman pertaining to Resident #1's discharge to the hospital. During an interview on 4/14/26 at 4:15 p.m. the SSD said she had been working at the facility since 1/27/26. She said she initially was not aware that she needed to notify the ombudsman whenever a resident was discharged from the facility until recently this month. She said once she learned that it was a requirement, she sent the ombudsman an email with the list of names of all the residents that had been discharged home since she started working at the facility. She said she was informed she was required to send a monthly list to the ombudsman of residents discharged home. She said she was not aware that the ombudsman was not notified or resident's discharges since October of last year. She said she did not get information for residents who were hospitalized , return anticipated and never returned. She said she was not aware of Resident #1's discharge on [DATE] since she started working at facility on 1/27/26. She said the prior SSD was working at the time. She said the ombudsman would need to be informed of Resident #1's discharge to the hospital because it was a discharge that was anticipated to return and never did. She said residents could miss out on any follow ups if the facility was not aware of the discharges. She would not directly answer what the outcome would be if the ombudsman was not notified. During an interview on 4/15/26 at 12:44 p.m. the ADM said she was not aware the ombudsman had not received notifications of resident's discharges since October 2025. She said the ombudsman should have been notified if Resident #1 was discharged to hospital in January 2026 with a return anticipated and did not return. She said she was not sure what the negative outcome of not notifying the ombudsman of resident discharges would be because the ombudsman did not divulge that information to them. During an interview on 4/14/26 at 3:11 p.m. the state managing local LTC Ombudsman stated she had not received any discharge notices from the facility since 10/3/25. 2. Record review of Resident #53's admission Record dated 04/15/26 revealed an [AGE] year old male with an admission date of 03/04/26. Resident #53 had a diagnoses of Chronic Systolic (Congestive) Heart Failure (heart muscle doesn't pump blood as well as it should), Peripheral Vascular Disease (blockage in the blood vessel outside the heart) and Presence of Cardiac Pacemaker (implanted device that regulates the heart rhythm). Record review of Resident #53's MDS discharge date d 03.20.26 revealed Resident #53 was Independent in Cognitive Skills for daily Decision making. Section Q indicated Discharge Plan was activated and already occurred for Resident #53 to return to the community. Record review of Resident #53's Discharge Summary & Post-Discharge Plan of Care dated 03.20.26 revealed Resident #53 was discharged home on 03.20.26. Record review of Resident #53's Plan of Care dated initiated: 03/05/26 revealed Resident #53 wished to return/discharged home. Discharge goals were to return home within next review date. Record review of Resident #53's electronic medical record from 03/04/26 to 03/20/26 revealed no evidence of notice given to the LTC Ombudsman pertaining to Resident #53's discharge to home. During an interview on 04/14/26 at 4:16 am the SSD stated she started sending notifications earlier this month via email to the Local Ombudsman. The SSD said she was overseen by a corporate office licensed social worker but was not informed of notifying the Local Ombudsman. During an interview on 04/15/26 at 2:37 pm the Administrator stated she was not aware the local ombudsman had not been notified of resident discharges from the facility. She said she was not aware that the facility was required to be sending the Local ombudsman resident discharge notifications. She said she was not aware the previous SSD had stopped sending notifications and did not know why she had stopped. In an Email communication on 04/14/26 at 3:32 pm, the Ombudsman revealed that she had not received any resident discharge notices from the facility since 10/3/25. Record review of the facilities policy titled Criteria for Transfer and Discharge, date revised: April 2024 stated:Procedure: .2.a. The facility will notify State Long-Term Care Ombudsman of discharges.b. The notice shall be made when resident is transferred or discharged or as soon as practicable before transfer or discharge when: . An immediate transfer or discharge is required by the resident's urgent need; or A resident has not resided in the facility for 30 days.9. If the Facility determines that a resident, who was transferred with an expectation of returning to the Facility cannot return to the Facility, this constitutes a discharge and this policy shall apply.

Based on interviews and record reviews, the facility failed to ensure resident medical records were kept in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for 1 of 4 residents (Resident #1) reviewed for clinical records. The facility failed to ensure the ADON entered the verbal physician orders that she took from the nurse practitioner immediately in Resident #1's records on 03/19/2026. This failure could place residents at risk for incorrect treatment decisions, evaluation, and treatment plans compromising patient safety due to insufficient information records.Findings include: Record review of Resident #1's face sheet, dated 04/11/2026, reflected a 74 -year-old male who was admitted to the facility on [DATE], with an original admission date of 03/15/2024. Resident #1 had diagnoses which included Congestive Heart Failure (a chronic condition where the heart doesn't pump blood as efficiently as it should, leading to blood backing up and fluid buildup in the lungs, legs, and body), Acute Respiratory Failure (a life-threatening, sudden condition where your lungs cannot get enough oxygen into the blood or remove carbon dioxide from it), and Chronic Obstructive Pulmonary Disease (a progressive, treatable, but incurable lung disease that causes chronic airflow restriction, making it hard to breathe). Record review of Resident #1's Quarterly MDS assessment, dated 03/19/2026, reflected he scored an 8 on his BIMS, which reflected he was moderately cognitively impaired. Record review of Resident #1's Progress Note, entered by the ADON, dated 03/19/2026, reflected new verbal orders received from the nurse practitioner, stat Chest Xray, stat EKG, and Stat Troponin. Record review of Resident #1's Physician's Orders, dated 03/19/2026, reflected Troponin order was entered by RN A, Chest Xray entered by the ADON, and the EKG was entered by RN A. Theses orders were to be entered by the ADON and not by RN A. In an interview on 04/11/2026 at 10:10 a.m. with the ADON, stated she was the person who took the verbal orders from the nurse practitioner on 03/19/2026. She stated RN A was Resident #1's floor nurse and she delegated those orders to him. The ADON stated whoever took the verbal order was responsible for entering them into the resident's record. She stated she was extra set of hands at the time and was not Resident #1's nurse. The ADON stated she should have entered all the orders in Resident #1's record because she was the one who took the verbal orders from the nurse practitioner. She stated the negative outcome of not entering the order in the record when getting the verbal order was that it could cause delays in treatment. Attempted interview with RN A on 04/11/2026 at 10:33 a.m., was unsuccessful. Left voicemail to return call. In an interview on 04/11/26 at 11:57 a.m., the DON stated staff that took the verbal order and was responsible for entering it in the resident's record. The ADON was supposed to enter verbal orders of stat Troponin, stat Chest Xray, and the stat EKG since she was the one who took these orders from the nurse practitioner. She only entered the stat Chest Xray order and delegated the Troponin and EKG orders to be entered by RN A. The order should have the physician's name, instructions, date, and time the order was given. The DON stated that the negative outcome for not entering the order after receiving the verbal order may delay necessary interventions and potentially lead to further deterioration in the resident's condition. In an interview via phone on 04/11/2026 at 12:13 p.m., RN A stated he was the nurse for Resident #1 on 03/19/2026. RN A stated he did not take the orders from the nurse practitioner. He stated the ADON told him the Troponin and the Chest Xray needed to be ordered. RN A stated he entered these orders and called the lab as well. He stated the person who took the verbal order was the one responsible for entering it in the resident's record. RN A stated the negative outcome of not following policy would be a delay in care. In an interview on 04/11/2026 at 1:30 p.m., LVN B stated the person who received the verbal order was responsible for entering it in the residents' records. The order should have the medication name, residents' name, frequency, dosage, time and date. LVN B stated the negative outcome of not entering the order when you received the verbal order would be an immediate decline in residents' condition. Record review of the facility's policy titled, Physician Orders, dated August 2022, reflected Policy: It is the policy of this facility that drugs shall be administered only upon the written order of a person duly licensed and authorized to prescribe such drugs. It is the policy of this facility to accurately implement orders in addition to medication orders (treatment, procedures) only upon the written order of a person duly licensed and authorized to do so in accordance with the residents plan of care . Procedures: 5.Verbal orders must be recorded immediately in the residents' chart by the person receiving the order and must include the date and time of the order.

Based on interview and record review the facility failed to maintain medical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices, for 1 of 2 residents (Resident #1) whose records were reviewed for accuracy and completeness. The facility failed to document in Resident #1's medical record when Resident #1 was sent to the hospital on [DATE] for evaluation to right heel wound. The facility failed to document the physician's order for evaluation to right heel wound. These failures could place residents at risk for errors in care. The findings Include: Record review of Resident #1's face sheet dated 2/19/26 revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included bed confinement status and peripheral vascular disease (a condition involving narrowed, blocked, or spasmodic blood vessels, usually in the legs, which reduces blood flow). Record review of Resident #1's MDS dated [DATE] revealed resident was at risk for developing a pressure ulcer. Record review of Resident#1's Care Plan last reviewed on 01/28/26 revealed, Focus- has pressure ulcer, unstageable to heel-DTI. Goal: pressure ulcer will show signs of healing and remain free from infection by/through review date. Interventions: Notify nurse immediately of any new areas of skin breakdown. During an interview on 02/19/26 at 7:20 PM, LVN A said that the LVN B informed her about Resident's #1 discoloration to her heel on 2/17/26, and that the doctor ordered for resident to be transferred to the emergency room for further evaluation. LVN A stated that she called the emergency room to give report to the emergency room nurse and that Resident #1 was transferred via ambulance. LVN A stated that she got busy with other residents and forgot to document that Resident #1 was transferred to the emergency room. LVN A stated that she knew documentation should have been done before shift ended. During an interview on 02/20/26 at 10:35 AM, LVN B stated that she did wound care to Resident #1 on 2/17/26. LVN B stated that she assessed Resident #1's heel and noted that Resident #1's heel was purple but not open. LVN B stated that she called the nurse practitioner and she gave a new order, to send Resident#1 to the emergency room for further evaluation. LVN B stated that she told LVN A about the new order and continued with another resident. LVN B said that she did not document the change in condition because she was not Resident#1's nurse and told LVN A who was the charge nurse. In an interview on 02/20/26 at 6:00 PM, the DON said the expectation was that documentation in resident charts are to be timely and accurate. She said nursing staff are expected to document change of conditions in real time but if unable to documentation should be completed prior to shift end. Record review of the facility's policy, Documentation Cares Given undated revealed It is the policy of this facility to ensure cares are provided as delineated within the service plan. Documentation of cares given is recorded by the care staff in the electronic record each shift

Based on interviews and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, for 13 ([DATE]th,10th, 23rd, 24th, and 31st, [DATE]th, 7th, and 21st, and [DATE]th, 18th, 19th, 25th, and 26th, 2025) of 90 days reviewed for RN hours, for the period from [DATE], through [DATE].The facility failed to have any RN coverage on weekends for [DATE]st, [DATE]th, 18th, 19th, 25th, and 26th, 2025.The facility failed to have less than 8 hours of RN coverage on weekends for [DATE]th,10th, 23rd, and 24th, and [DATE]th, 7th, and 21st, 2025.This failure could place residents at risk of harm by denying residents the advanced critical thinking skills a registered nurse could provide. The findings were: Record review of the facility's RN timesheets revealed no RN coverage on weekends for [DATE]st, and [DATE]th, 18th, 19th, 25th, and 26th, 2025.Record review of the facility's RN timesheets revealed less than 8 hours of RN coverage on weekends for [DATE]th,10th, 23rd, and 24th, [DATE]th, 7th, and 21st, 2025.In an interview with the DON and on [DATE] at 5:00 pm, she said there was not RN coverage every weekend. She said there were 4 RN's employed and only 1 worked weekends regularly. She said RN's assigned on weekends were not necessarily inside the building unless they were called. She said she was not aware of the rule about having RN's work 8 consecutive hours a day, 7 days a week. The DON said it was her responsibility to ensure the facility had RN coverage for 8 consecutive hours every day. She said if the scheduled RN were to call in, then it would be her and the ADON's responsibility to look for another RN, or she would have to cover the shift. The DON said the negative outcome of not having an RN in the facility for 8 consecutive hours could be that certain tasks only an RN could do (i.e., signing off on baseline care plans, removing midline/PICC (peripherally inserted central [intravenous] catheter) catheters, and/or pronouncing a resident deceased ) could not be performed. Policy(s) for Staffing/RN Coverage/Scheduling were requested, but not received prior to exit.In an interview with the ADM and RN A on [DATE] at 1:15 p.m., the ADM said that it was the DON's responsibility to ensure she scheduled an RN for 8 consecutive hours every day, but ultimately it was her responsibility as the Administrator. RN A said the negative outcome of not having an RN work 8 consecutive hours every day could be that the tasks that only an RN could perform, like pronouncing a death or being a resource in case of an emergency or a sudden illness. The Administrator said the facility had sufficient RNs to cover their 8 consecutive hours shift every day and did not know why it was not done. She said the facility followed Best Practices. Policy(s) for Staffing, RN Coverage, Scheduling, and best practices were requested but not received prior to exit. In an interview with the ADM and RN A on [DATE] at 3:30 pm, the ADM said she checked with another ADM at their sister facility, and they did not have the policies requested. She said the only policy she could find was a job description for the DON position. RN A said he was unaware of any specific policies the company had for scheduling or RN coverage.Record review of the facility's job description for the DON dated 10/2021 revealed under Position Summary: To assist in the management and direction of the nursing department in accordance with federal, state, and local standards, guidelines, and regulations that govern our facility.to ensure that the highest degree of quality care is maintained at all times.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 3 residents (Residents #1 and #2) reviewed for care plans. 1.The facility failed to ensure Resident #1's care plan reflected he was a 2 person assist for toileting. 2. The facility failed to ensure Resident #2's care plan reflected he was a 2 person assist for toileting. These failures could place residents at risk of not receiving the necessary care and services. Findings include: 1.Record review of Resident #1's admission record, dated 05/15/25, reflected a [AGE] year-old male admitted on [DATE], and an initial admit date of 03/08/25. Pertinent diagnoses included muscle weakness, lack of coordination, and difficulty in walking. Record review of Resident #1's 5-day MDS assessment dated [DATE], reflected a BIMS score of 06, which indicated his cognition as severely impaired. Further review reflected a functional limitation in range of motion due to impairment on both sides of his lower extremities, and dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) for toileting. Record review of Resident #1's care plan dated 05/06/25, reflected a focus of ADL self-care performance deficit r/t weakness . Care plan did not indicate if he was a 1 or 2 person assist for toileting. Record review of Resident #1's [NAME] report (a kiosk CNAs use to identify if a resident is a 1 or 2 person assist and enter their ADLs for the day) dated 05/14/25 did not reflect a task for toileting. 2.Record review of Resident #2's admission record, dated 05/15/25, reflected an [AGE] year-old male admitted on [DATE], and an initial admit date of 08/06/24. His relevant diagnoses included dementia (a group of thinking and social symptoms that interferes with daily functioning), Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), and sciatica- right side ( pain radiating along the sciatic nerve, which runs down one or both legs from the lower back). Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected that a brief interview for mental status should not be conducted due to resident rarely/never being understood. Further review reflected he had a functional limitation in range of motion due to upper and lower extremities and dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) for roll left to right (the ability to roll from lying on back to left and right side and return to lying on back on the bed). For the task of toilet transfer he was coded as not attempted due to medical condition or safety concerns. Record review of Resident #2's quarterly care plan dated 03/11/25 reflected he had a focus of ADL self-care performance deficit r/t weakness, sciatica to right side, dementia, and Alzheimer's disease. His interventions failed to indicate if he was a 1 or 2 person assist for toileting. Record review of Resident #2's [NAME] report dated 05/14/25 failed to reflect if he was a 1 or 2 person assist for toileting. An observation and interview on 05/14/25 at 9:17 a.m., CNA A said Resident #1 and Resident #2 were total bed bound residents who required a 2 person assist for toileting. CNA A said if a CNA needed to check if a resident required a 1 or 2 person assist on their ADLs, they would check the resident's [NAME] report. She was observed checking Resident #1 and Resident #2's [NAME] report and said it did not indicate if they were a 1 or 2 person assist for toileting. CNA A said she had cared for Resident #1 and Resident #2 since they had been admitted and knew they both were a 2 person assist for toileting. She was observed as she checked Resident #1's [NAME] report and stated his report did not have the ADL of toileting listed. CNA A said Resident #2's [NAME] report had his ADL of toileting listed but did not indicate if he was a 1 or 2 person assist for this specific task. CNA A said if a resident's [NAME] report failed to indicate the ADL of toileting and did not indicate if they were a 1 or 2 person assist, a CNA would not know how to provide the ADL of toileting. An interview with MDS-RN on 05/14/25 at 9:30 a.m. said the information listed on a resident's care plan was from what was listed on their MDS assessment. She said both Resident #1 and Resident #2 were considered dependent for all their ADLs which meant, both required a 2 person assist for toileting. She said their care plans did not reflect they were a were a 2 person assist for toileting and neither did their [NAME] report. She said a resident's [NAME] report reflected what was on their care plan. She said she had failed to care plan Resident #1 and Resident #2 were a two person assist for toileting. MDS-RN was not able to say if there were any negative outcomes to Resident #1 and/or Resident #2 not having their care plan indicate if they were a 1 or 2 person assist for toileting, she said that was a question for the DON. An interview on 05/14/25 at 10:03 am, the DON said Resident #1 and Resident #2 were both bed bound residents who required a 2 person assist for their ADL of toileting. The DON said the information listed on a resident's [NAME] report, was what was on their care plan. She said there were no negative outcome for Resident #1 and Resident #2 for not having their task of toileting on their care plans/[NAME] report because the CNAs assigned to their hall were tenured and had worked with both Resident #1 and Resident #2 since they had been admitted . The DON said a PRN or new CNA would check the residents [NAME] report to guide them in performing their ADL tasks. She said if a specific ADL was not listed on a resident's [NAME] report, the CNA could always ask their charge nurse for assistance. Record review of facility's Comprehensive Person-Centered Care Planning (no date) reflected: Policy: It is the policy of this facility that the interdisciplinary team (IT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in a comprehensive assessment. The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instruction needed to provide effective and person-centered care that meet professional standards of quality of care. Procedure: 4. The facility IDT will develop and implement a comprehensive person-centered care plan for each resident within 7 days of completion of the MDS and will include resident's needs identified in the comprehensive assessment, any specialized services as a result of PASRR recommendation, and resident's goal and desired outcomes, preferences for future discharge and discharge plans.

Based on interviews and record review, the facility failed to offer a therapeutic diet when there was a nutritional problem and the health care provider ordered a therapeutic diet for 1 (Resident #1) of 3 residents reviewed for diets. The facility failed to administer Resident #1 with liquid protein (on 02/28/25, 03/02/25, 03/03/25, 03/04/25, 03/08/25, 03/09/25, 03/10/25, 03/11/25, 03/12/25, 03/14/25, 03/16/25, 03/17/25, 03/19/25, 03/20/25, 03/21/25, and 03/24/25) and Nepro (on 02/28/25, 03/01/25, 03/03/25, 03/04/25, 03/06/25, 03/07/25, 03/09/25, 03/12/25, 03/13/25, 03/15/25, and 03/24/25) supplements as ordered by her physician. This failure could affect residents on therapeutic diets by placing them at increased risk for significant weight loss and malnutrition. Findings include: Record review of Resident #1's face sheet dated 05/01/25 reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: cerebral infarction (stroke), muscle weakness, type 2 diabetes (high levels of sugar in blood), unspecified protein-calorie malnutrition (does not consume enough protein or calories which can lead to weight loss or malnutrition), hypertension (high blood pressure), anemia (low iron levels), peripheral vascular disease (narrowing or blockage of blood vessels), end stage renal disease, and dependence on renal dialysis. Record review of Resident #1's MDS assessment dated [DATE] reflected Resident #1 had a BIMS score of 8, indicating moderate cognitive impairment. Resident #1 was noted to be at risk for malnutrition (protein or calorie). Nutritional approaches included a mechanically altered diet and a therapeutic diet. Record review of Resident #1's Mini Nutritional assessment dated [DATE] reflected Resident #1 was at risk of malnutrition with a score of 9. Resident #1's BMI was less than 19 (underweight). Record review of Resident #1's care plan dated 05/01/25 reflected Resident #1 had a nutritional problem or potential nutritional problem related to risk for malnutrition due to diagnoses of cerebral infarction, hypertension, diabetes, anemia, and ESRD with dialysis. Date initiated: 02/26/25. Interventions included: renal diet mechanical soft with thin liquids. Date initiated: 02/27/25. Liquid protein as ordered for 30 days. Date initiated: 02/27/25. Nepro. Date initiated: 02/28/25. Record review of Resident #1's order summary dated 05/01/25 reflected dietary supplements - Resident #1 was ordered liquid protein one time a day for risk for malnutrition. Give 30 ml for days. Start date: 02/28/25. Resident #1 was ordered Nepro (specialized nutritional product designed for individuals on dialysis) one time a day for supplement 118 ml. Start date: 02/28/25. Record review of Resident #1's MAR reflected - Liquid protein was not administered on 02/28/25, 03/02/25, 03/03/25, 03/04/25, 03/08/25, 03/09/25, 03/10/25, 03/11/25, 03/12/25, 03/14/25, 03/16/25, 03/17/25, 03/19/25, 03/20/25, 03/21/25, and 03/24/25. Nepro was not administered on 02/28/25, 03/01/25, 03/03/25, 03/04/25, 03/06/25, 03/07/25, 03/09/25, 03/12/25, 03/13/25, 03/15/25, and 03/24/25. Record review of Resident #1's progress notes reflected - On 02/28/25 at 4:40 PM - Medication Administration Note for Nepro, one time a day for supplement. Need clarification on supplement. Nurse notified. Documented by: CMA E On 03/03/25 at 4:30 PM - Medication Administration Note for Nepro, one time a day for supplement. Need clarification on supplement (quantity). Nurse notified. Documented by: CMA E On 03/04/25 at 8:18 AM - Medication Administration Note for liquid protein, one time a day for risk for malnutrition, give 30 ml for 30 days. Pending clarification in which protein to give. Nurse notified. Documented by: CMA E On 03/04/25 at 4:54 PM - Medication Administration Note for Nepro, one time a day for supplement. Need clarification on supplement. Documented by: CMA E On 03/06/25 at 3:11 PM - Medication Administration Note for Nepro, one time a day for supplement. Need clarification on supplement. Documented by: CMA D On 03/09/25 at 7:46 AM - Medication Administration Note for liquid protein, one time a day for risk for malnutrition, give 30 ml for 30 days. Pending clarification in which protein to give. Nurse notified. Documented by: CMA D On 03/09/25 at 4:50 PM - Medication Administration Note for Nepro, one time a day for supplement. Need clarification on supplement. Documented by: CMA D On 03/11/25 7:26 AM - Medication Administration Note for liquid protein, one time a day for risk for malnutrition, give 30 ml for 30 days. Pending clarification in which protein to give. Nurse notified. Documented by: CMA D On 03/12/25 at 3:25 PM - Medication Administration Note for Nepro, one time a day for supplement 118ml. Needs clarification on Nepro 118 ml. Nurse notified. Documented by: CMA E On 03/14/25 9:31 AM - Medication Administration Note for liquid protein, one time a day for risk for malnutrition, give 30 ml for 30 days. Pending clarification in which protein to give. Nurse notified. Documented by: CMA D On 03/15/25 4:49 PM - Medication Administration Note for Nepro, one time a day for supplement. Need clarification on supplement. Documented by: CMA E On 03/16/25 7:25 AM - Medication Administration Note for liquid protein, one time a day for risk for malnutrition, give 30 ml for 30 days. Pending clarification in which protein to give. Nurse notified. Documented by: CMA D On 03/19/25 11:12 AM - Medication Administration Note for liquid protein, one time a day for risk for malnutrition, give 30 ml for 30 days. Pending clarification in which protein to give. Nurse notified. Documented by: CMA D On 03/24/25 8:24 AM - Medication Administration Note for liquid protein, one time a day for risk for malnutrition, give 30 ml for 30 days. Pending clarification in which protein to give. Nurse notified. Documented by: CMA D Record review of Resident #1's weights dated 05/01/25 reflected Resident #1 weighed 117 pounds on 02/26/25 and 119 pounds on 03/04/25. Record review of Resident #1's meal percentage task dated 05/08/25 reflected from 03/11/25-03/24/25 Resident #1 ate between 51-100% for most meals. On 05/07/25 at 12:35 PM, in an interview with CMA D, she said there was a resident that she recalled she did not give the liquid protein and Nepro to because she needed clarification on the orders. CMA D said she did not remember the resident's name but she remembered that situation. CMA D said the order did not have the quantity or dosage, or she needed clarification on something, so she could not administer the supplements. CMA D said when that happened, she documented and notified the nurse. CMA D said she did not remember the specific nurse or date/time that she needed the clarification for but she remembered following those steps. CMA D said she did not remember if she ever got clarification on those orders. On 05/07/25 at 1:00 PM, in an interview with CMA E, he said he recalled asking the nurses for clarification on Resident #1's orders. CMA E said he needed clarification on the liquid protein as the order did not specify what kind of protein to use. CMA E said he also needed clarification for Nepro because the orders said to give 118 ml but the cups they use did not have show 118 ml, only showed 120, 130, 140 ml. CMA E said the nurses rotated so it was not one specific nurse he notified but he did his part in informing the nurse, and the nurse would have taken over from there and possibly called the doctor to get clarification. CMA E said he was unsure if he got clarification on those orders. On 05/08/25 at 11:15 AM, in an interview with the DON, she said Resident #1 had physician's orders for liquid protein and Nepro. The DON said she reviewed Resident #1's file and it appeared that the med aides needed clarification on these orders such as which kind or brand of liquid protein to use and the ml for the Nepro. The DON said the med aides did not receive clarification on these orders and Resident #1 was not administered the supplements. The DON said she was unsure of how many times or days were missed. The DON said the root cause of how they went many days without clarification was lack of follow up or miscommunication. The DON said the med aides administered those supplements but since they documented and signed off on the order, then the clarification was not obtained or followed up on. The DON said they identified this issue on 05/01/25 during a chart audit. The DON said she implemented a change for the med aides to not sign off on the MAR so that it stays red in the system and the nurses must follow up on those orders. The DON said Resident #1 had the orders for liquid protein and Nepro because she was at risk for malnutrition based on her assessments. The DON said Resident #1 did not have any weight loss and ate well. The DON said she informed the staff and this was an on-going in-service. The DON said Resident #1 was not at risk of any negative outcomes because the liquid protein and Nepro were for risk of malnutrition but Resident #1 still had a good appetite and good meal intake. The DON said there was no specific policy available for the process of how med aides inform the nurse when they need clarification on orders, then the nurse reaches out to the doctor. The DON said she was working on the in-service which would turn into a policy.

Based on interviews and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 (Resident #1) of 3 residents reviewed for accuracy of records, in that: LVN A failed to document Resident #1's change of condition for nausea on 03/24/25. This failure could affect residents whose records are maintained by the facility and could place them at risk for errors in care. The findings included: Record review of Resident #1's face sheet dated 05/01/25 reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: cerebral infarction (stroke), muscle weakness, type 2 diabetes (high levels of sugar in blood), unspecified protein-calorie malnutrition (does not consume enough protein or calories which can lead to weight loss or malnutrition), hypertension (high blood pressure), anemia (low iron levels), peripheral vascular disease (narrowing or blockage of blood vessels), end stage renal disease, and dependence on renal dialysis. Record review of Resident #1's MDS assessment dated [DATE] reflected Resident #1 had a BIMS score of 8, indicating moderate cognitive impairment. Record review of Resident #1's care plan dated 05/01/25 reflected Resident #1 had risk for acute/chronic pain related to diagnosis and disease processes. Date initiated: 02/26/25. Interventions included: Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician. Report to nurse any change in usual activity attendance patterns or refusal to attend activities related to signs/symptoms or complaints of pain or discomfort. Date initiated: 02/26/25. Record review of Resident #1's stop and watch form dated 03/24/25 at 2:10 PM reflected Resident #1 seemed different than usual, ate less, was tired/weak/confused, and stated she felt nauseous. Form completed by SLP G and reported to LVN A. Nurse response: pending orders. Record review of Resident #1's chart on 05/01/25 reflected LVN A did not document a form or note regarding the change of condition when Resident #1 experienced nausea. On 05/07/25 at 12:50 PM, in an interview with LVN A, she said on 03/24/25 during the day shift, a therapy staff (did not remember who) informed her that Resident #1 was not feeling well. LVN A said she followed up with Resident #1 and she said she felt nauseous. LVN A said she notified the physician but did not recall if they gave any new orders or said to just monitor. LVN A said she did not recall if she documented a form or note for the change of condition. On 05/07/25 at 2:00 PM, in an interview with SLP G, she said on 03/24/25 at around 2 PM, Resident #1 looked different so she completed a stop and watch where she noted the change. SLP G said Resident #1 told her she did not feel like eating as she felt nauseous. SLP G said she completed the form, reminded Resident #1 to use the call light, and informed Resident #1 she would notify the nurse. SLP G said she informed and gave the stop and watch form to LVN A. SLP G said LVN A said she would notify the physician and was pending orders from what she recalled. On 05/07/25 at 8:30 PM, in an interview with LVN B, she said on 03/24/25, LVN A informed her during shift change that Resident #1 had felt nauseous during the day shift and that she notified the physician. LVN B said she did not recall if the physician gave new orders or if Resident #1 was given any new medications. On 05/08/25 at 11:15 AM, in an interview with the DON, she said she did not recall if there was a change of condition for Resident #1 on 03/24/25. The DON said if a therapy staff did a stop and watch (form where they noted a change), and gave the form to the nurse, the nurse would have had to notify the physician, physician would have given an order or maybe just said to monitor. The DON said the nurse would have carried out orders or documented the result of the notification to the physician. The DON said she did not see any documentation on Resident #1's chart on 03/24/25 regarding a change such as her feeling nauseous. Record review of the facility's Daily Skilled Nursing Documentation policy dated 05/2023 reflected - Policy statement: All skilled services provided to the resident receiving skilled level of care, or any changes in the resident's medical or mental condition shall be documented in the resident's medical record. 6. Documentation of direct skilled nursing services, procedures, and treatments shall include care-specific details and shall include at a minimum: a. date/time b. name and title of the licensed nurse c. the assessment/evaluation data or any unusual findings f. notification of family, physician, or other staff g. conversation with physician or other staff

Based on interviews and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 2 (Resident #1 and Resident #2) of 3 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #1 and Resident #2 were coded in the MDS for dialysis. This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. The findings included: Record review of Resident #1's face sheet dated 05/01/25 reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: cerebral infarction (stroke), muscle weakness, type 2 diabetes (high levels of sugar in blood), unspecified protein-calorie malnutrition (does not consume enough protein or calories which can lead to weight loss or malnutrition), hypertension (high blood pressure), anemia (low iron levels), peripheral vascular disease (narrowing or blockage of blood vessels), end stage renal disease, and dependence on renal dialysis. Record review of Resident #1's MDS assessment dated [DATE] reflected Resident #1 had a BIMS score of 8, indicating moderate cognitive impairment. Dialysis was not coded for section O: special treatments, procedures, and programs. Record review of Resident #1's care plan dated 05/01/25 reflected Resident #1 had renal failure related to end stage disease. Date initiated: 02/26/25. Resident #1 needed dialysis related to ESRD. Date initiated: 02/26/25. Record review of Resident #2's face sheet dated 05/01/25 reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: chronic kidney disease (progressive loss of kidney function), muscle weakness, unspecified protein-calorie malnutrition (does not consume enough protein or calories which can lead to weight loss or malnutrition), hypertension (high blood pressure), end stage renal disease, and dependence on renal dialysis. Record review of Resident #2's MDS assessment dated [DATE] reflected Resident #2 had a BIMS score of 15, indicating intact cognition. Dialysis was not coded for section O: special treatments, procedures, and programs. Record review of Resident #2's care plan dated 05/01/25 reflected Resident #2 had renal failure related to end stage disease. Date initiated: 06/17/24. Resident #2 needed dialysis related to ESRD. Date initiated: 06/17/24. On 05/07/25 at 4:00 PM, in an interview with MDS F, she said section O of the MDS assessment was completed by the MDS nurses. MDS F said she reviewed the MDS assessments for Resident #1 and Resident #2. MDS F said she agreed that dialysis was not coded correctly for the residents MDS assessments. MDS F said there was no negative outcome to the residents and they would not be at risk of a negative outcome as the MDS assessment section O was not used to care plan, but rather as a billing tool. MDS F said they would correct the assessments for payment and audit accuracies. On 05/07/25 at 4:30 PM, in an interview with the DON, she said for the MDS coding, section O did not trigger care areas to develop the care plans for dialysis. The DON said the care plans included dialysis for Resident #1 and Resident #2. The DON said they would modify the assessments for accuracy and for payment. The DON said there was no negative outcome or risk of injury for the residents as that section of the MDS assessments was used for billing. Record review of the facility's Resident Assessment and Associated Processes policy dated January 2022 reflected - Policy: It is the policy of this facility that resident's will be assessed and the findings documented in their clinical health record. The comprehensive assessment includes the completion of the MDS as well as the Care Area Assessment process. An accurate comprehensive assessment will include special treatments and procedures. Record review of CMS's RAI Version 3.0 Manual dated 10/2024 reflected section O: O0110: Special Treatments, Procedures, and Programs Coding instructions: Review the resident's medical record to determine whether or not the resident received or performed any of the treatments, procedures, or programs within the assessment period defined for each column (on admission, while a resident, and at discharge).

Based on interviews and record review the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident needs, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 (Resident #1) of 5 residents reviewed for care plans. The facility failed to develop a comprehensive person-centered care plan for Resident #1 to address her behaviors (e.g. not offloading, not wearing heel protectors, weight bearing, refusing to attend dialysis, drinking soda or too much fluid, and not following dietary recommendations such as eating fried chicken). This failure could place the residents at risk of not receiving appropriate interventions and care to meet their current needs as indicated on the comprehensive care plans. The findings included: Record review of Resident #1's face sheet dated 04/09/25 reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: fracture of orbital floor (skull fracture), muscle weakness, unsteadiness on feet, type 2 diabetes (high levels of sugar in blood), end stage renal disease, edema (fluid retention, swelling in the body's tissues), hypertension, heart disease, heart failure, peripheral vascular disease (narrowing/blocking of the blood vessels outside of the heart), and dependence on renal dialysis. Record review of Resident #1's MDS assessment dated [DATE] reflected Resident #1 had a BIMS score of 15, indicating intact cognition. Resident #1 was at risk of developing pressure ulcers. Record review of Resident #1's care plan dated 04/09/25 reflected Resident #1 had renal failure related to end stage disease. Date initiated: 01/30/25. Resident #1 needed dialysis related to ESRD . Date initiated: 01/30/25. Resident #1 had a nutritional problem or potential nutritional problem related to risk for malnutrition due to diagnoses. Date initiated: 01/30/25. Interventions included: diet as ordered by MD - renal diet, regular texture with thin liquids and 1.5 liter fluid restriction. Resident had arterial ulcer of the left heel. Date initiated: 03/21/25. Right medial 4th toe and right medial 5th toe. Date initiated: 03/24/25. Right lateral ankle and left lateral ankle. Date initiated: 03/29/25. Interventions included: antibiotics, arterial doppler to bilateral lower extremities, labs, heel protectors, treatment per order, and observe/report to MD changes in status. Resident #1's care plan did not reflect behaviors (not offloading, not wearing heel protectors, weight bearing, refusing to attend dialysis, drinking soda or too much fluid, and not following dietary recommendations such as eating fried chicken). Interview with CMA F on 04/15/25 at 11:00 AM revealed CMA F said Resident #1 was getting wound care but Resident #1 was not keeping on her heel protectors like she was supposed to in order for her feet to not have pressure. CMA F said Resident #1 removed the heel protectors and was always sitting up in her chair. Interview with RN C on 04/15/25 at 3:25 PM revealed RN C said Resident #1 was on a fluid restriction because she received dialysis, but Resident #1 was always asking for ice. RN C said she explained to Resident #1 that ice melted into water and that could cause fluid overload but Resident #1 was very adamant that she wanted ice. RN C said Resident #1 called the dialysis center herself and canceled her treatment appointments. RN C said she explained to Resident #1 the importance of her receiving dialysis but she was still able to make those decisions and refused to go. RN C said they ordered waffle boots (heel protectors) and therapy evaluated Resident #1 to help address Resident #1's wounds. RN C said therapy indicated that Resident #1 should not bear weight on her feet because the wounds were getting worse. RN C said Resident #1 was non-complaint and tried to stand on her feet especially when her family took her out on pass. RN C said they explained the importance of not bearing weight to Resident #1 and her family, but they did not know if they followed the recommendations when they took Resident #1 out on pass. RN C said Resident #1's family brought her food all the time such as fried chicken, crackers, or food from restaurants that were unhealthy and did not aid in wound healing. Interview with the ADON on 04/15/25 at 3:55 PM revealed the ADON said Resident #1 had arterial wounds on her heels. The ADON said Resident #1 had very poor circulation and had diabetes. The ADON said Resident #1 received dialysis but she drank sodas and did not like to stay off her feet or offload. The ADON said she would place a pillow under Resident #1's feet to help relieve pressure but Resident #1 would remove the pillow. Interview with the DON on 04/15/25 at 5:10 PM revealed the DON said Resident #1's family brought her outside food such as food from a steak house and fried chicken which had too much sodium. The DON said Resident #1 received dialysis and refused to follow the renal diet or fluid restrictions. The DON said they ensured to document and explained the risks of not following the diet. The DON said Resident #1 liked to drink sodas and liked ice. The DON said they explained the limit on the fluids but Resident #1 still asked her family to bring her what she wanted. The DON said the wounds Resident #1 had were arterial wounds. The DON said Resident #1 had the offloading booties (heel protectors) but she did not leave the booties on. The DON said they explained the importance of her wearing them. The DON said Resident #1 was educated that the booties were to help prevent the wounds from getting worse. The DON said she was informed maybe of one time that Resident #1 refused to go to dialysis but she was unsure if it was more than that or if there was a history of Resident #1 refusing dialysis. The DON said Resident #1's non-compliance with care should have been care planned. The DON said those behaviors of noncompliance would place residents at risk for their condition to worsen, not improve, or other adverse effects, so they should have ensured the behaviors were care planned. The DON said it was important for Resident #1's behaviors to be care planned so that staff were aware and knew what to do if Resident #1 exhibited behaviors. The DON said the care plan would have reflected the interventions implemented specific for Resident #1's behaviors such as to redirect, re-educate, and document that she was made aware of the adverse effects of being noncompliant. The DON said if it was not care planned, maybe it was not communicated to the IDT. The DON said any changes noted such as noncompliance with care were noted by staff and should have been communicated with the team so that they could have developed interventions and updated the care plan. The DON said she was not sure why Resident #1's behaviors were not care planned. The DON said the renal diet, fluid restriction, heel protectors, offloading, and dialysis were important for wound healing. The DON said if the behaviors were not care planned, that could result in Resident #1's condition worsening. Record review of the facility's Comprehensive Person-Centered Care Planning policy dated December 2023 reflected - Policy: It is the policy of this facility that the interdisciplinary team shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs that are identified. 5. The resident has the right to refuse or discontinue treatment. In the event that a resident refuses certain services posing a risk to resident's health and safety, the comprehensive care plan will identify care or service declined, the associated risks, IDT's effort to educate the resident and resident representative and any alternate means to address risk.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 of 1 resident (Resident #1) reviewed for accidents. The facility failed to ensure an exit door was secured to prevent elopement. Resident #1 eloped from the facility on 9/19/24 and was found by hospital security guards. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 9/19/24 and ended on 10/3/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of sustaining serious injury, harm, and death. Findings included: Record review of Resident #1's electronic facility face sheet dated 1/24/2025, revealed he was an [AGE] year-old male admitted to the facility on [DATE]. He had diagnoses of mild protein-calorie malnutrition, muscle weakness, and other reduced mobility. Record review of MDS dated [DATE] indicated Resident #1 had moderately impaired cognition with a BIMS score of 10 out of 15. The MDS revealed his mobility functional abilities for self-care were partial/moderate assistance to supervision or touching assistance. Resident #1 had no wandering behavior. Record review of Resident #1's undated care plan revealed elopement from facility on 9/19/24. Interventions included assess for fall risk and document wandering behavior and attempted diversional interventions. Date Initiated: 09/19/2024. Record review of the Incident Report dated 9/19/24 revealed at 9:15 am, MA A noted resident not in his room. Staff alerted and 100 % head count completed, then on-site and off-site search initiated. Facility driver called facility to inform Resident #1 had been in front of neighboring hospital with hospital security guards. DON arrived where resident was located, and resident returned to facility via facility van at approximately 9:58 am. No injuries noted to resident, but resident complained of pain to right knee. As per security guards, resident was found on sidewalk in the grass on his knees and stated he lost balance and fell . Resident voiced wanted to go fishing. Immediate Action Taken: MD, DON, and RP notified. Full body assessment completed. Vital signs taken and within normal limits, resident sent out to ER for evaluation. Record review of SBAR Communication Form dated 9/19/24 completed by RN B, revealed resident had change of condition: patient eloped from facility on 9/19/24, it was unknown if resident had any elopement prior, and resident had increased confusion or disorientation. Record review of the Nursing note dated 9/19/24 completed by DON, revealed elopement risk assessment done by RN B and Resident #1 is high risk and is currently at hospital per MD order. Record review of a History and Physical from hospital Resident #1 was admitted from dated 9/12/24, revealed no previous elopement history. Record review of nursing note dated 9/19/24 revealed at 9:15 am MA A noted Resident #1 was not in his room and could not be found throughout facility. Staff alerted and immediately completed 100% resident head count. On-site and off-site search began immediately, and resident found within minutes across parking lot at neighboring hospital with 2 security guards. Resident brought back to facility via facility van. As per security guard resident was found on sidewalk in the grass on his knees and stated he lost balance and fell . Visual assessment initially completed with no visible abnormalities. Resident stated pain to right knee. Upon arrival to facility, at approximately 9:58 am head to toe assessment completed. Resident's speech clear and coherent and able to answer questions appropriately when asked. No visible injuries or abnormalities noted. No new skin issues noted. Placed call to MD and received orders to transfer resident to ER for evaluation. Placed call to RP and made aware of elopement and transfer to ER. injuries noted to resident, but resident noted with confusion. Record review of document dated 9/19/24 by unknown author with question on first line that says, What was done to prevent incident from reoccurring? revealed Within less than an hour of elopement, maintenance director activated the sound on the East Hall door which was identified as the door the resident used to exit the building. All staff present were in serviced on alarm sound and directed to no longer use East door for regular exit purposes. Record review of the provider investigation report dated 9/26/24 indicated in an interview on 9/19/24 at 10:12 am by DON, Staff A stated during med pass she noticed resident was missing and stated looking for him and couldn't find him, so notified ADON at time that he was missing. Record review of the provider investigation report dated 9/26/24 indicated in an interview on 09/19/2024 at 10:56 am by DON, with RN B stated Resident #1 was last seen resting in room after he ate breakfast. Record review of the Wanderguard Checklist revealed Exit Doors for Main Entrance, Elevator, Bistro, Chandelier, Stairs 1200 Hall, Stairs 1100 Hall, and Hall 1100 were being checked daily from 9/20/24 to 12/31/24. Record review of the Weekly Checklist for Wander System: Door Devices revealed the door devices were checked on 9/19/24, 9/21/24, 9/23/24, 9/27/24, 9/29/24, and 10/1/24. The logs revealed the facility continued to assess door devices from 10/4/21 to 12/20/24 sporadically. Beginning 12/30/24 to 1/17/15 the door devices were checked daily Monday - Friday. Record review of Abuse, Neglect and Exploitation and Elopement in-services and Drills revealed they were conducted on the day of elopement for 1st and 2nd shift on 9/19/24 at 6:35 pm and 9/20/24 at 10:00 am. Record review of Elopement Drills revealed they were conducted for 1st and 2nd shifts on 9/19/24 and 9/20/24, 9/23/24 and 9/24/24, 9/25/24, 10/1/24, 10/4/24, 10/25/24, and 12/20/24. Record review of Head Count of resident head count document revealed 100 % head count conducted on 9/19/24 and 9/20/24. All residents accounted for on 1st and 2nd shifts. Record review also revealed 100% head count were conducted on 9/21/24, 9/23/24, 9/25/24, 9/27/24, 9/30/24, 10/2/24, 10/4/24, 10/7/24, 10/9/24, and 10/11/24. Record review of the Elopement Risk Re-evaluation revealed it was conducted on 9/19/24, 10/15/24, 11/2024, 12/2024 and 1/2025. In an interview on 1/24/25 at 10:31 am CNA F said the facility had elopement trainings prior to incident but since the incident they were more frequent. She said when an alarm goes off, they must look to see where it was coming from. She said if a resident was missing, everyone looked for the resident and they didn't stop until they found them. In an interview on 1/24/25 at 12:16 pm MA A stated that she didn't remember much due to Resident #1 arrived the evening before. MA A said she was the medication aide for that day. She said she was making rounds about to do med pass and Resident #1 was not in room. She said she was not sure of the time but was in the morning. She said she usually started med pass around eight beginning in the 1200 hall first, then began med pass in 1100 hallway. She said she does not remember the alarm going off. She said once she reported it, everyone went out to go search for Resident #1. She said that Resident #1 was new. She said he arrived at the facility the evening before, so there was no opportunity to hear him saying he wanted to leave. In an interview on 1/24/25 at 12:30 pm RN B stated that she remembered working that day and somebody noticed Resident #1 wasn't in his room in the morning, so an elopement code was started immediately. RN B said she did not remember a time frame of when she last saw Resident #1. She said she did not remember hearing an alarm go off. She said Resident #1 was new, but she didn't think he was a wanderer. RN B said she thinks he left through the door at end of 1100 hallway. She said she is not sure, but she thinks it is always locked. In an interview on 1/24/25 at 1:05 pm with the Maintenance Supervisor he said, upon inspection of the alarm system for exit door down hallway 1100, they learned the alarm for that exit door was silenced. He said they immediately turned the alarm sound back on with laptop. He said it could have been turned off by the IT person that was servicing the system 3 to 4 days before. Maintenance Supervisor said they checked the doors weekly prior to the elopement, but no log was kept. He said now they keep a log of all door checks. He said the facility put a plan of correction in place and it was still ongoing. He said they check the doors daily to ensure they were locked and now the door alarms are checked weekly to ensure the alarms go on every time the doors open. He said they must check the doors for 6 months. In an interview on 1/24/25 at 1:22 pm RN G said she was working on the 1200 hall when heard that a resident was missing. She said all staff stopped and searched for the resident. They searched inside and outside of the facility, and the resident was located approximately 20 minutes later. She said prior to the incident they had in-services on elopement, but after the incident they had them more frequently. She said all staff must look if a door alarm or wander guard alarm goes off. If it was an actual elopement, they used walkies to inform everyone and all staff must stop and search for the resident. She said they completed a head count to ensure all residents were accounted. She said they do not stop searching until the resident was located. In an interview on 1/24/25 at 2:43 pm with the facility's Driver, he said on the morning of 9/19/24, while driving towards the facility he saw Resident #1 sitting at the neighboring hospital with security. He turned back and they asked if resident was from the nursing facility he worked for, and he said yes. The Driver said security would not release Resident #1 without identification. The Driver called the facility and informed the person who answered where the resident was. The DON was informed, and she arrived at the hospital with a face sheet and ID. They released him and brought him back to facility in the van. It took about 15 minutes in total to get him back to the facility. Driver said resident was walking and doesn't remember resident limping. He said resident stated he wanted to go fishing. He said resident really didn't say much more. In an interview on 1/25/25 at 10:28 LVN H said the facility had elopement in-services and drills when she worked on the weekends. She said elopements were called code yellow on the walkies. She said they must check inside the building and then check outside the building. She said they do not stop searching until the resident was located. She said a head count was completed to ensure all residents were accounted for and they must always notify the MD, RP, DON and Administrator when there was an actual elopement. In an interview on 1/25/25 at 11:10 LVN D said the facility had done multiple code yellow trainings and drills. He said elopements were called code yellow. He said if they heard an alarm go off, they must lookd to figure out the source. He said if a resident was missing, they do a head count then it's all hands-on deck to make sure they find the resident as soon as possible. If resident is located, MD and family were notified. If the resident can not be located, the authorities must also be contacted. He said the resident was assessed, an investigation was done, and resident and staff were re-educated. The plan of care was modified as needed and the resident could be placed on a wanderguard if indicated. In an interview on 1/25/25 at 12:32 pm with the DON, she said around 9:15 am she was notified resident was not found in his room. While the search was ongoing, the front desk received a phone call from the Driver that Resident #1 was seen at the neighboring hospital with 2 security guards and they wouldn't release him without some type of identification that he belonged at the facility. The DON said she went with resident's information and when resident was released to their care, he was brought back in the facility's van. She said they notified RP and MD, and they received orders to send resident to the emergency room for evaluation. The DON said Resident #1's wife met the resident at the facility and went with the resident to the emergency room . The DON said she felt the resident was confused due to new environment. The DON said Resident #1 was admitted to facility the day before on 9/18/24 in the evening, and the elopement happened the next morning. The DON said the resident walked out the exit door from the 1100 hallway. The DON said there was an alarm on that door, but it did not go off when resident left. The DON said the Maintenance Director looked at the door and made corrections. The DON said prior to the elopement on 9/19/24, elopement training was done. The DON said elopement training was done upon hire and annually. She said that after the elopement on 9/19/24, elopement trainings and drills were done. She said they had elopement drills twice a week for 2 weeks and 100% head count twice a week for 2 weeks. DON said staff was in-serviced on code yellow for elopement. The DON said there have been no other elopements since. In an interview on 1/25/25 at 12:43 pm ADON said elopement in-services had been done at the facility and that drills were done frequently. He said for the elopement drills, they used radios and called out code yellow. He said they go room by room and searched the premises for the resident. He said they contact law enforcement if they resident was not located. He said that the family, DON and administrator were always contacted when a resident was missing. He said they do not stop searching for the resident until they were located. In an interview on 1/25/25 at 1:45 pm with the Administrator. She said that for the elopement on 9/19/24, once they found out that someone was missing, they did a head count. They then called a code yellow, so everyone knew to start looking. All staff check inside and outside of the facility. She said this would be done for any elopement and they don't stop looking until the resident is found. The RP and MD were called once he was found, and he was sent out to the hospital for evaluation. Staff completed a new elopement risk evaluation because the status has changed. The Administrator said the nurses usually have 24 hours to complete the elopement assessment, but they try to get them as soon as they can when they come in. The Administrator said for all elopements a wander guard would be placed, and the information would be placed into a binder kept at the nurse's station. The Administrator said that Resident #1 did not return to the facility from the hospital. The Administrator said they provided in-services on Abuse and Neglect and Elopement for all staff. The Maintenance Supervisor assessed the door and learned the alarm had been silenced, so he turned it back on. She said they initiated a plan of correction which included 100 % head counts for residents, weekly tests of the door alarms and elopement drills for the next couple of weeks. During an observation on 1/24/25 at 1:05 pm, this surveyor observed the exit door in the 1100 hallway that Resident #1 used to exit the building along with the Maintenance Director. The Maintenance Director opened the door, the alarm sounded, then he entered the alarm code into the keypad located on the inside of the facility to turn the alarm off. The front entry door alarm was observed in working order throughout the the survey. During an observation on 1/24/25 at 3:00 pm, the elopement binder was observed at the nurse's station and staff were aware of which residents had exit seeking behavior. During an observation on 1/24/25 at 5:30 pm, this surveyor noted that the path the resident took to the neighboring hospital had a busy street the resident would have crossed. This street brought in traffic from the hospital and from another street which includes all types of vehicles entering and exiting to get to the hospital, medical offices, and the Facility including ambulances and the Facility's own van. The time the resident walked to the neighboring hospital would have been a busy weekday. Record review of Elopement/Unsafe Wandering policy with date revision/review of 12/2023 revealed: Policy: It is the policy of this facility to provide a safe environment, as free of accidents as possible, for all residents through appropriate assessment, interventions, and adequate supervision to prevent accidents related to unsafe wandering or elopement while maintaining the least restrictive manner for those at risk for elopement. Definitions: .Elopement occurs when a resident leaves the premises or a safe area without the authorization (i.e. an order for discharge, appointment, or leave of absence), and/or any necessary supervision to do so. The Administrator was notified on 1/24/2025 at 5:00 pm, that a past noncompliance Immediate Jeopardy situation had been identified due to the above failures. It was determined these failures placed Resident #1 in an Immediate Jeopardy situation on 9/19/24. The facility had corrected the noncompliance before survey began. The facility had implemented the following interventions as per Provider Investigation Report dated 9/26/24: 1. Head to Toe Assessment completed 2. Notification of MD 3. Notification of RP 4. Clinicians initiated and completed 100% re-evaluations for elopement risk and no other new residents were identified as medium to high risk All new admissions to be reviewed within 24hr by DON/designee and LN staff educated/inserviced to notify DON/designee of any new admissions flagging medium to high risk on UDA. In-service on Abuse and Neglect and Elopement initiated and completed 6. 100% of resident head count was conducted by licensed nurses at time of incident and all active residents accounted for and Facility initiated 100% of head count qshift x48hr 9/19124 & 9/20/24. 100% Head count will continue 3xW 2nd shift x2 weeks 7. East exit door sound activated on door resident used to elope through. 8. Maintenance director tested all doors with alarms to ensure alarm sounds at in working order. Maintenance director/designee will test alarm sounds 3xW x2 consecutive weeks for working order. 9. Alert system placed to residents left wrist 10. Elopement drills initiated on 09/19/24 and continued on 9/19/24. Effective 9/23/24 elopement drills will be conducted 2xW for both 1st and 2nd shift for a period of 2 weeks Record review of Nursing note dated 9/19/24 revealed Resident #1's family member picked up his belongings at the facility. The family member stated she was overwhelmed with resident's gradual decline and has decided to go to another city to live with a family member, and where another family member lives a block away, to help her.

Based on observations, interviews, and record reviews the facility failed to store all drugs and biologicals under proper temperature controls, for 1 of 3 (black fridge) refrigerators in the medication storage reviewed, in that, The black fridge was not maintained between ,d+[DATE] degrees as per facility policy. This failure placed residents at risk for harm by not receiving the therapeutic effects of their medications. The findings included: During an observation accompanied by the Administrator, of the medication storage room located behind the front desk on [DATE] at 11:13 AM the temperature inside the black fridge was at 45 degrees F. Checked refrigerator again at 11:55 AM and temperature was at 50 degrees F. The black refrigerator contained insulins and eye drops. The temperature log located at the side of the refrigerator revealed the temperature should read between ,d+[DATE] degrees F. If not notify Supervisor immediately. In an interview on [DATE] at 11:10 am LVN D he stated the night nurses were in charge of checking the temperatures on the refrigerators located in the medication storage room. He said if the temperature was above or below the recommended range, the medications located in the refrigerator could expire and no longer be effective. In an interview on [DATE] at 11:55 am LVN E said checking the temperatures of the refrigerators in the medication room were one of her responsibilities. She said she did not check the black refrigerator on [DATE] because it had already been checked off by one of the other night nurses. She said she did not recall who. She said if the refrigerator was not in the recommended range on the log, the medication could go bad. She said they must read the directions on each medication. She said if she noticed the temperature was not within the recommended degrees she must report to maintenance, ADON, DON and document. She said they would probably have to call the pharmacy to get assistance. She said she received training on medications needing refrigeration during orientation. In an interview on [DATE] at 12:43 pm with the ADON, he said refrigerator temperatures in the medication storage room were checked by night nurses. He said as the ADON, he and DON must verify the next day to ensure it was checked nightly by the night shift. He said that morning he did not check the log. He said if the refrigerator was not kept within the recommended temperatures, the medication could go bad. He said they must also take into consideration what the labels of each medication recommend. He said he does not recall the protocol for what to do if the temperature was out of range because he was still in training. In an interview on [DATE] at 1:25 pm with the DON, she said the night nurses check the temperatures on the refrigerators. She said if the refrigerator was not within the recommended range, the medications could no longer be effective, and she would have to re-order those medications. She said she reviews medication requiring refrigeration with nurses upon hire and annually. Record review of the Refrigerator Temperature Log for the Black Refrigerator dated [DATE] reflect the temperature has been checked daily from [DATE] to [DATE] and temperatures ranged from 36 degrees F to 39 degrees F. The last temperature documented was the night shift of [DATE] at 36 degrees F. Record review of the facility's Storing and Controlling Medications policy revealed, Policy: It is the policy of this facility to: 1. Store medications safely, securely, and properly following manufacturer's recommendations or those of the supplier, and in accordance with federal and state laws and regulations. 8. Medications requiring storage in the refrigerator will be kept by the staff in the medication room refrigerator. Refrigerated temperatures will be maintained between ,d+[DATE] degrees Fahrenheit. 9. Medications that are discontinued, expired, contaminated, or deteriorated, .are immediately removed from the locked medication storage area and disposed of in accordance with the Facility policies and procedures.

Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 5 (Resident #39) residents reviewed for respiratory care. The facility failed to ensure Resident #39's oxygen was administered at the correct setting of 3 liters per minute on 01/22/2025 as ordered by the physician. This deficient practice could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care. The findings included: Record review of Resident #39's face sheet dated 01/22/2025 reflected an [AGE] year-old female with an admitted [DATE]. Pertinent diagnoses included Acute and Chronic Respiratory Failure with Hypoxia (a condition where you don't have enough oxygen in your body), Bronchiectasis (condition that occurs when the tubes that carry air in and out of your lungs get damaged, causing them to widen and become loose and scarred), Idiopathic Pulmonary Fibrosis (a disease that causes scarring (fibrosis) of the lungs), Allergies, Primary Hypertension (high blood pressure), and Depression Unspecified. Record review of Resident #39's MDS assessment, dated 01/10/2025 reflected continuous oxygen therapy. Resident #39's BIMS score of 15, indicating cognitively intact. Record review of Resident #39's comprehensive person-centered care plan, dated 01/16/2025 reflected Resident #39 has altered respiratory status/difficulty breathing r/t Acute and Chronic Respiratory Failure with Hypoxia, Bronchiectasis, Idiopathic Pulmonary Fibrosis, Allergies. Intervention Provide oxygen as ordered. Record review of Resident #39's physician order summary, dated 01/22/2025, reflected oxygen at 3 L/min via nasal cannula continuous every shift. During an observation of Resident #39 on 01/22/2025 at 02:35 p.m. revealed the oxygen level on the oxygen concentration machine to be at 1L/min via nasal cannula. Observed Resident #39 in bed, awake. No signs of respiratory distress noted. In an interview on 01/22/2025 at 2:37 p.m. with Resident #39 stated, she was admitted about two weeks ago and was doing well. She denied any chest pain, shortness of breath or headache. In an interview on 01/22/2025 at 2:40 p.m. with RN B, stated she was the nurse for Resident #39. RN B verified that the O2 setting was set at 1L/min. She stated she did not know what the setting was supposed to be at and needed to check in the computer. RN B then logged onto her computer, reviewed Resident #39's oxygen setting physician order and stated it was supposed to be set at 3L/min. RN B stated the person responsible for checking that the oxygen setting was correct, was the person who put it on Resident #39. In this case, it was the night shift nurse who was supposed to check the oxygen setting and change the tubing. RN B stated her shift started at 6 a.m. and she had not checked the oxygen setting today. She stated that she normally does but she was working on a discharge. RN B stated that she did her rounds this morning upon shift change but did not look at her oxygen concentrator. RN B stated that when she checks the resident's oxygen, she checks their vital signs, checks that it was the right dose, humidifier, that the concentrator was working, that all the tubing was in place, and that the resident was connected to the nasal cannula or mask. RN B stated she has had respiratory care training in the past but cannot remember of exact date. She stated the negative outcome to keeping Resident#39's oxygen setting at 1L/min was that she can get short of breath and be in respiratory distress. In an interview on 01/22/2025 at 2:52 p.m. with the DON, stated that the floor nurse was responsible for checking the resident's oxygen setting. She stated that the facility has angel rounds, where the department heads check them daily in the morning before the 9 a.m. meeting. The DON stated the nurse should check the oxygen setting whenever she goes into the room, and as needed. She stated that training was provided for oxygen administration upon hire and annually. The DON stated that the negative outcome to keeping Resident#39's oxygen setting at 1L/min was that she can get hypoxia and go into respiratory distress. In an interview on 01/25/2025 at 3:35 p.m. with the ADON stated the nurses, the DON, and himself are responsible for checking the resident's oxygen setting. He stated the nurses are to check the oxygen setting each shift and they are to monitor them throughout the day. The ADON stated they are to follow oxygen setting physician orders. He stated that the nurses get respiratory care training upon hire and annually. The ADON stated the negative outcome to keeping Resident#39's oxygen setting at 1L/min was that she was not getting enough oxygen and she can go into a medical emergency. Record review of the facility's policy subject titled, Oxygen Administration, dated December 2023, revealed, Policy: It is the policy of this facility that oxygen therapy is administered, as ordered by the physician or as an emergency measure until the order can be obtained. Purpose: The purpose of the oxygen therapy is to provide sufficient oxygen to the blood stream and tissues. Procedure: #13. Reassess oxygen flowmeter for correct liter flow.

Based on observation, interviews, and record review, the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing and prevent infections for 1 of 3 (Resident #19) residents reviewed for quality of care. The facility failed to ensure LVN C labeled and dated Resident #19's wound treatment dressing after completing wound care on 01/23/2025. This deficient practice could affect residents who receive wound care treatments by placing them at risk for receiving inadequate treatments resulting in the worsening of the wounds. The findings included: Record review of Resident #19's face sheet dated 01/24/2025 reflected a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Pertinent diagnoses included Cerebral Infarction (condition that affects blood flow to the brain), Right hip Osteoarthritis (the breakdown of cartilage that leads to pain and inflammation), Embolism and Thrombosis of superficial veins of left lower extremity (blood clot that occurs in veins under the skin), and Unspecified Protein-Calorie Malnutrition (a disorder caused by a lack of proper nutrition or inability to absorb nutrients from food). Record review of Resident #19's quarterly MDS assessment, dated 11/22/2024, reflected a BIMS score of 03, indicating severe cognitive impairment. Section M, titled Skin Conditions, indicated Resident #19 had one stage four pressure ulcer. Record review of Resident #19's comprehensive person-centered care plan, dated 12/31/2024, reflected Resident #19 had has pressure ulcer or potential for pressure ulcer development r/t cerebral infarction, Right hip Osteoarthritis, Embolism and Thrombosis of superficial veins of left lower extremity. Wounds to sacral area (large, triangular bone at the base of the spine), stage four. The interventions included monitor and report to physician as needed for any changes in skin status: signs and symptoms of infection, appearance, color, wound healing, wound size, stage, and treatments as ordered. Record review of Resident #19's physician order summary, dated 01/24/2025, reflected an order to cleanse sacral wound with wound cleanser, pat dry with gauze. Apply wet to dry (dakins solution) BID. May redress if dressing becomes soiled or dislodged as needed for Stage IV and cover with a dressing. During an observation of a wound treatment for Resident #19, on 01/23/2025 at 02:20 p.m., completed by LVN C. Resident #19's LVN C completed the wound treatment, redressed the wound, and did not label the dressing with date, time, and initials. Upon placing the dressing towards the bottom, LVN C realized Resident #19 had bowel movement and the edge of the dressing touched stool. LVN C completed the wound treatment again, redressed the wound, and again, did not label the dressing. In an interview on 01/23/2025 at 02:45 p.m. with LVN C, she stated she did not label the dressing because it slipped her mind. She stated that she always labels the dressings with her initials, time, and date. LVN C stated it was important to label the dressing with the initials, time, and date for when the doctor makes his rounds, and for other staff to know when it was changed. In an interview on 01/23/2025 at 03:06 p.m. the DON, stated the nurse was to initial, time, and date the wound dressings at the time the dressing was applied. The DON said the importance of dating, putting the time, and initialing the wound dressings was because it was the process, and it was the only way of knowing when the dressing was changed. The DON also stated that the negative outcome of not labeling dressing was that if it does not get changed, the wound can get worse and harbor bacteria. Record review of a facility document titled, Wound Care- Skills Checklist, undated reflected [NAME] tape with initials, time, and date and apply to dressing. Review of facility policy titled, Skin Management System revised date December 2019, reflected Policy: It is the policy of this facility that any resident who enters the facility without pressure ulcers will have appropriate preventive measures taken to ensure that the resident does not develop pressure ulcers, or that resident admitted with wounds will not develop signs and symptoms of infection, unless the residents clinical condition makes development unavoidable.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 6 residents (Residents #6), reviewed for pharmaceutical services, in that: The facility failed to ensure Resident #6 had his physician ordered Ceftriaxone sodium (antibiotic) available on 01/31/24. This failure could place residents at risk for not receiving medication as ordered. The findings included: Record review of Resident #6's face sheet, dated 11/21/24, revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses that included: acute (sudden) respiratory failure (abnormal levels of oxygen and carbon dioxide in the blood) with hypoxia (not enough oxygen to the body), diabetes mellitus due to underlying condition with hyperglycemia (high blood sugar), essential (primary) hypertension, (blood pressure that is higher than normal), acute kidney failure (a sudden decline in kidney function that can range from minor to complete kidney failure) urinary tract infection (bladder infection, an illness in any part of the urinary tract), site not specified. Record review of Resident #6's admission Minimum Data Set assessment, dated 02/03/24, revealed Resident #6 had a BIMS score of 14 indicating cognition was intact. Resident #6's MDS also revealed he was taking an antibiotic. Record review of Resident #6's care plan, with an initiation date of 01/31/24 stated Resident #6 was on antibiotic therapy related to sepsis and had an intervention to administer medication as ordered. Record review of Resident #6's physician's orders, retrieved on 11/2/24, revealed an order for cefTRIAXone Sodium Injection Solution Reconstituted 2GM with start date on 01/31/24 with scheduled time of 4:00pm. Record review of Resident #6's January 2024 medication administration record revealed RN A documented a 7 on Resident #6's scheduled ceftriaxone on 01/31/24 at 4:00pm which indicated Other/ See Nurse Notes. Record review of Resident #6's medication administration note regarding his order for ceftriaxone that was written by RN A on 01/31/24 at 7:47 PM stated, medication not in facility faxed to pharm. During an interview with Pharmacy Tech B on 11/20/24 at 4:33pm she stated the order for Ceftriaxone had an order date of 01/31/24 at 12:43pm and a printed date of 01/31/24 at 8:06PM. Pharmacy Tech C stated they received the order on 02/01/24 at 9am and sent out the medication STAT and stated it was delivered to the facility on [DATE] at 12:08pm. During an interview and record review of the pulled pyxis inventory with Pharmacy Director C on 11/20/24 at 4:51pm he stated 2 vials of ceftriaxone were pulled from the pyxis on 02/01/24 at 8:31am and stated there had not been any restock noted and stated the medication was in the pyxis the entire time and was there on 01/30/24. During an interview with Pharmacy Director C on 11/21/24 at 10:21am he stated he did not think there was any negative impact on a resident if they missed one dose of an antibiotic. Pharmacy Director C stated the antibiotic would need to be started as soon as possible. During an interview on 11/20/24 at 2:19pm with RN A she stated they didn't really have anyone appointed to be responsible for ensuring newly admitted residents had their medications available as ordered. RN A stated it would be up to the admitting nurse to speak to the ADON. RN A stated if a resident was admitted in the middle of the night, and they needed a medication and had an order for a medication later that day then they would need to check the pyxis and put in the order as soon as the order had arrived. RN A stated if the medication is due right then and there and was not available then they needed to contact the MD. RN A stated she recalled Resident #6 and stated he had either a midline or picc line. RN A believed Resident #6 had been on antibiotics but was unsure how far into his stay that was. RN A was unable to recall if Resident #6's antibiotics were available or not. RN A explained the note she wrote on 01/31/24 at 7:47pm about medication not being available and faxing information to the pharmacy. RN A stated that was what they needed to do if the medication was not available in the pyxis and stated that it probably was not available. RN A stated the pharmacy they used made deliveries 2 times a day. RN A stated she was unable to pinpoint if she had contacted the MD about Resident #6's antibiotic medication not being available or any alternative options. RN A stated the nurses were responsible for notifying the MD about medication not being available and any alternative options. RN A stated it was important for residents to get their antibiotics because they were on it due to some sort of infection. RN A stated if residents did not get their antibiotics as ordered it could negatively impact their health and cascade into other problems. RN A stated the previous ADON D used to audit their admissions and make sure they weren't missing any assessments or medications. RN A stated she had been trained during orientation on ensuring residents had their physician ordered medications available and what to do if they did not. RN A stated she did not know the facility policy for ensuring residents had access to their physician ordered medications off the top of her head but stated she did know it had to be done as fast as possible and stated when NPs wrote orders they wanted them done then. RN A stated because she didn't know the exact policy, she was not sure if she followed her facility policy or not. Record review of clock in times on 1/30/24 revealed both LVN E and LVN F worked at the time of Resident #6's admission. Record review of Resident #6's admitting assessments on 01/30/24 revealed LVN E completed them. During an interview with LVN E on 11/20/24 at 6:04pm she stated she did not recall Resident #6. LVN E stated the nurses and whoever had done the admission was responsible for ensuring residents had their medications available as ordered. LVN E stated if a resident was admitted at night, she would go through the pyxis to check if they had the medication available and if it was not available then she would call the pharmacy to see how quickly they could get it. LVN E stated if she is doing an admission, she needs to verify all the medication with the MD and once they got clarification on the medications such as IV medications, she would then have to fax the IV orders, batch orders and resident face sheet over to the pharmacy otherwise the pharmacy could not send over the medication. LVN E stated she did have access to the pyxis. LVN E stated she did not recall anything about Resident #6 or his admission and was unable to answer if he had his antibiotics available at the time of admission. LVN E stated she was not sure what time the pharmacy delivered during the day but stated they did deliver at night around 8:30pm/9pm. LVN E stated if residents didn't get their antibiotics as ordered they won't get better and could get worse. LVN E stated management would check to ensure residents had their ordered medications available. LVN E stated she had been trained over ensuring residents had their physician ordered medication available and the procedures to get them if not available. LVN E stated she followed her facility policy regarding ensuring residents had access to their physician ordered medication. During an interview with LVN F on 11/21/24 at 12:47pm he stated he did not recall Resident #6 and stated that he was taught to put the orders in the system and wait until the medication got delivered. LVN F stated he had been taught that if they did not have the medication to check the pyxis and if it was not found there then to contact the pharmacy to see what was going on and if not then they had to write a medication administration note and document that they were pending the medication. LVN F stated from what he understood it was the ADON or DON who monitored to ensure residents had their ordered medication available but was not sure of how that process was done. During an interview with the DON on 11/21/24 at 2:20pm she stated she was not employed at the facility when Resident #6 was a resident and stated she started working at the facility on 08/04/24 and was not familiar with Resident #6. The DON stated based off what she saw in the chart Resident #6 was admitted on [DATE] and had orders for ceftriaxone on 01/31/24 and was scheduled at 4:00pm but RN A put a note that medication was not in the facility and was faxed to the pharmacy. The DON stated Resident #6 was then given a dose of his ceftriaxone on 02/01/24. The DON stated it was everyone's responsibility including the admitting nurse and the all the shifts after to ensure Resident #6 had his antibiotic available. The DON stated she did not see any documentation of them trying to get the medication. The DON stated the process staff should follow was to put in the orders and it would go to the pharmacy but also to send over IV medication orders via fax otherwise the pharmacy would not get it. The DON stated she was not sure if that was the same process previously. The DON stated staff should also check the pyxis and if it's not there then they should be calling the MD to see if they need to put the medication on hold or give something different that they may have available. The DON stated all nursing staff should have access to the pyxis. The DON stated she was not able to review the pyxis inventory from 01/31/24 and was only told by pharmacy staff that the medication Ceftriaxone was pulled on 01/31/24 but stated she had not seen that. The DON was not sure if staff checked the pyxis or reached out to the MD about any substitutes for Resident #6's medication and stated all she knew is what she saw in the chart. The DON stated it was important to ensure residents were provided their medication as scheduled to continue the course and follow it to get rid of any infection and because they did not want any adverse reaction. The DON stated it was important for the staff to be trained on checking the pyxis in order to get the medication for their residents and to start or continue their medication and not have any breakage in the medication. The DON was not sure if RN A and LVN E had been trained over checking the pyxis of procedures to follow when medication was not available. The DON stated they did not have a policy for verifying residents' medications were available and stated it was more of a procedure that they provided staff during orientation than a policy. The DON was unable to answer if staff followed their procedure and stated at that time she had no idea what they did because nothing was documented. The DON stated not getting a dose of antibiotic could throw off a medication regimen and may prolong the infection. During an interview on 11/21/24 at 5:58pm with the Clinical Resource she stated Resident #6 was admitted on [DATE] and had an order for ceftriaxone that started on 01/31/24 with a scheduled dose at 4:00pm that was not given. The Clinical Resource stated RN A documented on 01/31/24 at 7:47pm that medication was not in the facility, and she faxed information to the pharmacy. The Clinical Resource stated the admitting nurse is responsible for inputting the order and if there are any IV orders then they need to be faxed and stated the following nurse should make sure the pharmacy received it. The Clinical Resource stated LVN E was the admitting nurse. The Clinical Resource stated the process to check if medication was available was to fax the orders to the pharmacy and then check if the medication as available in the pyxis and if not then to contact the physician for a different medication. The Clinical Resource stated all nursing staff had access to the pyxis. The Clinical Resource stated she was unable to review inventory that was in the pyxis on 01/31/24. The Clinical Resource stated she did not know if staff checked the pyxis for Resident #6's medication or if they contacted the MD. The Clinical Resource stated it was important to ensure residents were provided their medications as scheduled so that they did not miss a dose. The Clinical Resource stated it was important for staff to be trained on checking the pyxis so that patients could get their medications. The Clinical Resource stated she saw a training for LVN E but could not find the training for RN A regarding procedures to follow when medication was not available. The Clinical Resource stated she could not find a policy regarding what should be completed when verifying resident's medications were available and stated it was more of a process. The Clinical Resource stated after looking at Resident #6's record he had already received 8 or 10 doses of his medication and she didn't know if he would be negatively impacted by not getting a dose but did state it was important for him to get his entire dose. During an interview on 11/21/24 at 5:58pm The Clinical Resource stated she could not find the training for RN A regarding procedures to follow when medication was not available. Record review of LVN E's nurse training skills check list dated 09/10/23 revealed she had been evaluated by a previous DON. LVN E's skills list did not have the met or not met sections checked off but did have a date of 9/10 on the side of the following titles, What medications can be found in the first dose machine (as applicable -Ekit) with a description of how to access first dose machine, Facility policy for medication unavailability, Pharmacy process and medication ordering/reordering process, and Demonstrated competency in transcribing new admissions orders. During an interview with the DON on 11/21/24 at 2:20pm she stated they did not have a policy for verifying residents' medications were available and stated it was more of a procedure. During an interview with the Clinical Resource on 11/21/24 at 5:58pm she stated she could not find a policy regarding what should be completed when verifying resident's medications were available and stated it was more of a process.

Based on interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and hazards. The facility failed to ensure Resident #1's environment remained free of hazards. On 06/19/24 at around 4:00pm - 6:00pm Resident #1 was found by the ADON with altered mental status and a bottle of rubbing alcohol that was 1/4 empty on a dresser at the foot of his bed after Medical Records staff had found 2 bottles of alcohol in residents room earlier in the morning. This deficient practice could place the residents at risk for harm, or serious injury. The findings were: Record review of Resident #1's face sheet, dated 06/24/24, revealed the resident was a [AGE] year-old male who was initially admitted to the facility on [DATE] with diagnoses that included: pulmonary hypertension (high blood pressure that affects the arteries in the lungs and in the heart), acute (severe and sudden onset) and subacute (recent onset, somewhat rapid change) endocarditis (inflammation of the heart valve), type 2 diabetes mellitus (high blood sugar) without complications, end stage renal disease (when kidneys no longer work as they should to meet the body's needs), and nicotine dependence ( need for nicotine that you cannot stop). Record review of Resident #1's admission minimum data set assessment (MDS), dated [DATE], revealed Resident #1 had a BIMS score of 14, indicating no cognitive impairment. The MDS assessment reflected Resident #1's independence level for eating was set up (helper sets up or cleans up; resident completed activity). Record review of Resident #1's change in condition dated 06/19/24 at 6:12pm completed by the ADON stated, unknown amount of rubbing alcohol missing from original bottle/consumed and stated the ADON was notified by dialysis center that resident had a large bottle of rubbing alcohol 1/2 bottle was empty, patient noted to be having altered mental stated when assessed and poison control called. Change in condition documentation stated Resident #1 was recommended to be sent to the emergency room for evaluation and treatment as per poison control and the FNP. Record review of Resident #1's nursing notes with an effective date of 06/20/24 at 3:46 am by LVN A revealed the nurse spoke to a nurse from the hospital who notified her that Resident #1 would be admitted for alcohol poisoning. Record review of Resident #1's hospital record dated 06/19/24 stated Resident #1 was seen on 06/19/24 and stated Resident #1 had stated he drank about 1/4 of rubbing alcohol because he wanted to get drunk. Hospital records revealed Resident #1 had an ethanol level of <10 mcg/ml on 06/19/24. During an interview with Resident #1 on 06/24/24 at 12:55pm while at the hospital he stated while at the facility he had 2 bottles of rubbing alcohol that he would keep with him or on the counter. Resident #1 stated he did not know if staff had seen the rubbing alcohol bottles but stated he did not have them hidden and had them in plain sight, but no one had said anything. Resident #1 then stated a lot of people would see the rubbing alcohol bottles but he did not recall exactly who. Resident #1 stated he used the rubbing alcohol for his legs since they were dry. Resident #1 stated he had not drank any and did not remember where he got it from. Resident #1 stated he was not sure If when he arrived at the facility they went over his inventory and completed an inventory sheet. Resident #1 stated upon admission the facility did not go over checking in any items that were brought in with himself or his responsible party. Resident #1 stated upon admission the facility had not explained to him or his responsible party items that were not allowed in the facility. During an interview and record review on 06/19/24 at 1:05 pm with Resident #1's Hospital Nurse he stated Resident #1 was admitted for some sort of ingestion of rubbing alcohol. Resident #1's Hospital Nurse reviewed his resident list that had their diagnosis and pointed to Resident #1 diagnoses, which read, isopropyl alcohol poisoning. During an interview with Medical Records on 06/24/24 at 4:21 pm she stated during her morning rounds that were completed before 8:30 am on 06/19/24 she found 2 bottles of rubbing alcohol in Resident #1's room. She stated there was 1 bottle of rubbing alcohol on his bed side table and another on his nightstand. Medical Records stated she did not know how full they were but stated Resident #1 was able to reach both. Medical Records stated Resident #1 should not have any bottles of rubbing alcohol. Medical Records stated she explained the regulations to Resident #1 and informed him that those items were not allowed. Medical Records stated she removed both bottles of rubbing alcohol and gave them to Resident #1's family member and explained that they were not allowed. Medical Records stated she did not know who brought in the rubbing alcohol bottles to Resident #1 and had not asked why he had them. Medical Records stated Resident #1 had not had rubbing alcohol bottles during her previous morning rounds unless they had been hidden. Medical Records stated she had not been made aware prior of anything related to Resident #1 having rubbing alcohol and stated no staff had mentioned seeing rubbing alcohol in his room. Medical Records stated she had not observed Resident #1 ingest any of the rubbing alcohol. Medical records stated she monitored and ensured residents did not bring in non-permitted by removing anything she saw that was not permitted. Medical Records stated she believed residents were educated when they were admitted over what's not permitted, she stated upon admission the admission coordinator would complete an inventory sheet for residents and would notify the resident if anything was brought in to go to the nurse's station and update their inventory sheet. Medical Records stated she had been trained over non permitted items and procedures to identify/prevent them from entering within the last month and stated some procedures used were completing their rounds, inventory sheets and informing residents and their family what Is and is not allowed. Medical Records stated having rubbing alcohol could negatively impact residents because not only could they drink it but stated because its medication he could be overdosing himself. During an interview with the ADON on 06/24/24 at 1:26pm she stated on 6/19/14 at around 4 or 5pm she was notified by the dialysis center that they had found a bottle of rubbing alcohol with Resident #1 on 06/18/24 while he was at dialysis. The ADON stated this prompted her to go to Resident #1's room immediately where she found a bottle of rubbing alcohol that had about 1/4 missing and Resident #1 very lethargic, not coherent, and slumped over. The ADON stated she did not see Resident #1 consume any of the rubbing alcohol but asked Resident #1 If he had consumed any and he stated he did not know if something was put in a cup at bedside. ADON stated she called poison control because it was a substance. During a follow up interview and record review with the ADON on 06/24/24 at 4:36pm she stated she had not seen Resident #1 with rubbing alcohol until identified on 06/19/24. The ADON stated when she found the bottle of rubbing alcohol, she asked to remove the bottle of alcohol that was located on the dresser at the foot of the bed and asked Resident #1 if he had consumed any to which he responded he was not sure If he did or not because he couldn't see. The ADON stated during previous interactions with Resident #1 he was alert and orientated and stated during their interaction on 06/19/24 he was a different person and stated, something was wrong. Resident #1 did not disclose to the ADON who brought him the rubbing alcohol and stated he did not know how long he had it. The ADON was not sure how long Resident #1 had the rubbing alcohol in his possession and stated she was aware that they had removed some rubbing alcohol from his room earlier and stated he should not have had the rubbing alcohol. The ADON stated no staff had mentioned seeing rubbing alcohol in his room. The ADON stated to monitor and ensure residents do not bring in non-permitted items they educate both residents and their families, complete an inventory of their belongings was completed upon admission. At this time the inventory sheet was reviewed with no rubbing alcohol identified. The ADON stated the IDT (interdisciplinary team) and staff had been in serviced on things that were permitted and not permitted such as cigarettes and lighters but was unsure the last time any 1 on 1 or Inservice had been provided. The ADON stated the procedures used to identify and prevent any non-permitted items from entering the facility was more of a check list over what the residents could and could not have, removing items, and notifying family. The ADON stated having rubbing alcohol could be deadly if consumed or could alter their mental status. During an interview and record review on 06/24/24 at 5:42pm with the Interim Administrator/Clinical Resource she stated she had not met Resident #1 but stated she was informed that Medical Records had found a bottle of rubbing alcohol, removed it and spoke to family member for Resident #1 about it not being allowed in Resident #1's room and about stopping at the nurses station to check in any other items he brought. the Interim Administrator/Clinical Resource was also aware that the ADON had found a bottle of rubbing alcohol but stated she had not been told where it was found and stated she just knew that all 3 found bottles were in Resident #1's room. The Interim Administrator/Clinical Resource stated Medical Records checked the room because it was her daily rounds and the ADON checked the Resident #1's room after being notified by dialysis center that they had found a bottle of rubbing alcohol on him the previous day 06/18/24. The Interim Administrator/Clinical Resource stated Resident #1 was hospitalized . The Interim Administrator/Clinical Resource reviewed hospital records and stated Resident #1 had impression of isopropyl alcohol poisoning and ethanol levels less than 10. The Interim Administrator/Clinical Resource stated staff had not seen Resident #1 with any rubbing alcohol previously and had not seen him ingest any rubbing alcohol but stated he should not have had the bottle of rubbing alcohol. The Interim Administrator/Clinical Resource stated Resident #1 had not stated who brought the rubbing alcohol to him or when. The Interim Administrator/Clinical Resource stated they monitored and ensured non permitted items were not in residents' possession or brought in by doing visual checks, asking questions if they have a suspicion, completing their angel rounds (daily rounds completed by leadership team) and completing inventory. The Interim Administrator/Clinical Resource stated Resident #1 did have an inventory sheet completed when admitted and no bottle of rubbing alcohol was identified. The Interim Administrator/Clinical Resource stated all staff was being trained over non permitted items and started that training on 06/21/24 and stated previously it had only been covered with the leadership team. The Interim Administrator/Clinical Resource stated having rubbing alcohol could negatively impact the residents if ingested it could cause stomach, gastritis and burning of the esophagus. Record review of facility in services revealed Medical Records and the ADON had both been trained over How to conduct proper angel rounds, state prep on 04/12/2023. Record review of the facility's admission packet section titled, FACILITY RULES, REGUALTIONS, POLICIES AND PROCEDURES included verbiage that stated, All residents are required to comply with the Facility's Resident Policies and Procedures, including the Facility Prohibition Against Illegal and Recreational Drugs. The section titled, PERSONAL AND OTHER PROPERTY stated, The facility reserves the right to require certain personal property to be removed from the premises: (i) for safe keeping, or (ii) if the use or possession of the personal property infringes on the rights, health, or safety of other residents.

Based on interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (which included to the State Survey Agency) in accordance with State law through established procedures for 1 of 4 residents (Resident #1) reviewed for reporting alleged allegation of abuse. The facility did not report, within 2 hours, when Resident #1 was found with altered mental status and a 1/4 empty bottle of rubbing alcohol on 06/19/24 at around 4:00pm - 6:00 PM. This failure could place residents at risk for undetected abuse, neglect and/or decline in feelings of safety and well-being. The findings were: Record review of Resident #1's face sheet, dated 06/24/24, revealed the resident was a [AGE] year-old male who was initially admitted to the facility on [DATE] with diagnoses that included: pulmonary hypertension (high blood pressure that affects the arteries in the lungs and in the heart), acute (severe and sudden onset) and subacute (recent onset, somewhat rapid change) endocarditis (inflammation of the heart valve), type 2 diabetes mellitus (high blood sugar) without complications, peripheral vascular disease, end stage renal disease (when kidneys no longer work as they should to meet the body's needs), nicotine dependence ( need for nicotine that you cannot stop) Record review of Resident #1's admission minimum data set assessment (MDS), dated [DATE], revealed Resident #1 had a BIMS score of 14, indicating no cognitive impairment. The MDS assessment reflected Resident #1's independence level for eating was set up (helper sets up or cleans up; resident completed activity). Record review of Resident #1's change in condition dated 06/19/24 at 6:12 PM completed by the ADON stated, unknown amount of rubbing alcohol missing from original bottle/consumed and stated the ADON was notified by dialysis center that resident had a large bottle of rubbing alcohol 1/2 bottle was empty, patient noted to be having altered mental stated when assessed and poison control called. Change in condition documentation stated Resident #1 was recommended to be sent to the emergency room for evaluation and treatment as per poison control and the FNP. Record review of Resident #1's nursing notes with an effective date of 06/20/24 at 3:46 am by LVN A revealed the nurse spoke to a nurse from the hospital who notified her that Resident #1 would be admitted for alcohol poisoning. Record review of Resident #1's hospital record dated 06/19/24 stated Resident #1 was seen on 06/19/24 and stated Resident #1 had stated he drank about 1/4 of rubbing alcohol because he wanted to get drunk. Hospital records revealed Resident #1 had an ethanol level of <10 mcg/ml on 06/19/24. Record Review of TULIP (HHSC online incident reporting application) on 06/24/24 at 6:30 PM revealed a self-report received by the facility on 06/20/24 at 3:09 PM, more than 2 hours after facility identified Resident #1 with a 1/4 empty bottle of alcohol and altered mental status. During an interview with Resident #1 on 06/24/24 at 12:55 PM while at the hospital he stated while at the facility he had 2 bottles of rubbing alcohol that he would keep with him or on the counter. Resident #1 stated he did not know if staff had seen the rubbing alcohol bottles but stated he did not have them hidden and had them in plain sight, but no one had said anything. Resident #1 then stated a lot of people would see the rubbing alcohol bottles but he did not recall exactly who. Resident #1 stated he used the rubbing alcohol for his legs since they were dry. Resident #1 stated he had not drank any and did not remember where he got it from. Resident #1 stated he was not sure If when he arrived at the facility they went over his inventory and completed an inventory sheet. Resident #1 stated upon admission the facility did not go over checking in any items that were brought in with himself or his responsible party. Resident #1 stated upon admission the facility had not explained to him or his responsible party items that were not allowed in the facility. During an interview and record review on 06/19/24 at 1:05 PM with Resident #1's Hospital Nurse he stated Resident #1 was admitted for some sort of ingestion of rubbing alcohol. Resident #1's Hospital Nurse reviewed his resident list that had their diagnosis and pointed to Resident #1 diagnoses, which read, isopropyl alcohol poisoning. During an interview with the ADN on 06/24/24 at 1:26 PM she stated on 6/19/14 at around 4 or 5 PM she was notified by the dialysis center that they had found a bottle of rubbing alcohol with Resident #1 on 06/18/24 while he was at dialysis. ADON stated this prompted her to go to Resident #1's room immediately where she found a bottle of rubbing alcohol that had about 1/4 missing and Resident #1 very lethargic, not coherent, and slumped over. ADON stated she did not see Resident #1 consume any of the rubbing alcohol but asked Resident #1 If he had consumed any and he stated he did not know if something was put in a cup at bedside. ADON stated she called poison control because it was a substance. During an interview with LVN A on 06/25/24 at 3:22 PM she stated the Interim Administrator/Clinical Resource was the abuse coordinator and stated any nurse who witnessed abuse was responsible for reporting any allegations of abuse, neglect, or exploitation to state agencies as well as reporting it to their ADON/DON. LVN A stated they had a couple of hours to report. LVN A stated on 06/20/24 sometime after 2:00 am she called the hospital to check the status of Resident #1 and was informed he was probably getting admitted for alcohol poisoning, but they were not sure due to pending lab results. LVN A stated she notified the ADON as soon as she hung up with the hospital. LVN A stated as far as reporting to stated agencies she was not sure if she could report it herself as that was usually taken care of by the abuse coordinator. LVN A stated she had been trained over this topic within the last month and stated trainings were either provided but the abuse coordinator or the DON. LVN A stated facility policy was to report as soon as you see something happening and stated in this situation, she did follow her policy. LVN A stated not reporting allegations of abuse, neglect or exploitation within the appropriate time frames could cause resident to injure themselves or overdose. During a follow up interview with the ADON on 06/24/24 at 4:36 PM she stated the Interim Administrator/Clinical Resource was the abuse coordinator and was responsible for reporting any allegations of abuse, neglect, or exploitation to state agencies along with DONs or Administrators from their sister facilities being responsible as well. The ADON stated they had a 2-hour window to report. The ADON stated she did not know the timeline of the facility submitted self-report but stated it should have been reported within 2 hours because Resident #1 ingested something. The ADON stated herself and staff had been trained over reporting and the appropriate time frames and stated their facility policy also stated to report within a 2-hour window. The ADON stated when she found Resident #1 with altered mental status and a bottle of rubbing alcohol in his room she reported to the Interim Administrator/Clinical Resource after she had assessed Resident #1 and called poison control to let her know she would be sending Resident #1 out to hospital. The ADON stated she reported to the Interim Administrator/Clinical Resource on 06/19/24 at around 4:30 PM-6:00 PM, closer to 6:00 PM. The ADON stated she was also notified by LVN A on 06/20/24 at 4:43 am that Resident #1 had been admitted with a diagnoses of alcohol poisoning and stated at around 6:00 am she had notified the Interim Administrator/Clinical Resource and a DON from a sister facility. The ADON stated not appropriately reporting allegations of abuse, neglect and exploitation could cause bodily injury or death. During an interview with the Interim Administrator/Clinical Resource on 06/24/24 at 5:42 PM she stated she was the abuse coordinator and was responsible for reporting any allegations of abuse, neglect, or exploitation to state agencies. The Interim Administrator/Clinical Resource stated the reporting time depended on their assessment and would be either 2 hours or 24 hours and stated they reported on a 24-hour time frame based off provider letter 19-17. The Interim Administrator/Clinical Resource stated on 06/19/24 at around 6:00 PM was when she was notified by the ADON of the dialysis center finding rubbing alcohol with Resident #1 the previous day 06/18/24, at this time the Interim Administrator/Clinical Resource was also notified of the ADON finding a bottle of rubbing alcohol in Resident #1's room and the results of the assessment completed by the ADON on Resident #1. The Interim Administrator/Clinical Resource stated she informed the ADON to call poison control and to send Resident #1 out. The Interim Administrator/Clinical Resource stated she submitted self-report on 06/20/24 at around 2:00 PM. The Interim Administrator/Clinical Resource stated she did not report with 2 hours because they were getting hearsay information from dialysis and stated no one at the dialysis center had witnessed Resident #1 ingest anything. The Interim Administrator/Clinical Resource stated after explanation by Surveyor B she agreed the situation was a more urgent situation and should have been reported within 2 hours. The Interim Administrator/Clinical Resource stated herself and staff had been trained over reporting and the appropriate time frames and stated staff was last trained over the topic within the last 30 days. The Interim Administrator/Clinical Resource stated she was not notified by LVN A when she got information that Resident #1 was admitted with a diagnosis of alcohol positioning and stated she was not sure if LVN A had notified the ADON. The Administrator stated the negative impact of not appropriately reporting allegations of abuse, neglect and exploitation within the appropriate time frame depended on the severity and stated if it was severe enough it could cause a negative impact. During an interview with the Interim Administrator/Clinical Resource on 06/25/24 at 5:24 PM she stated the following in services was all they were able to find. Record review of facility training dated 04/04/24 revealed the ADON had been trained over abuse and neglect. Record review of facility training dated 06/20/24 revealed LVN A had been trained over reporting abuse and neglect. Record review of the Interim Administrator/Clinical Resource's training transcript revealed she had completed a training titled, Obligation to Report Abuse Letter for Staff on 09/29/2023. Record review of facility policy titled Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment with a review date of 12/2023 specified, Procedure: 1. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility will: a. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately but not later than two (2) hours after the allegation is made if the events that cause the allegation involves abuse or results in serious bodily injury.

Based on interview and record review, the facility failed to establish and follow written policy on permitting residents to return to the facility after they were hospitalized for one (Resident #1) of one resident reviewed for transfer/discharge. The facility failed to admit Resident #1 back to facility after he was sent to the hospital on 08/04/23. This failure could place residents at risk of not receiving the care and services to meet their needs and could affect their mental and emotional well-being. The findings included: Record review of Resident #1's Admission Record dated 02/22/24 indicated resident was a [AGE] year-old male originally admitted to the facility on [DATE] with the diagnoses of Quadriplegia (paralysis from the neck down, including the trunk, legs, and arms), muscle weakness, and urinary tract infection. Record review of Resident #1's Quarterly MDS assessment dated [DATE] indicated Resident #1 was able to be understood by others, able to understand others, had a BIMS of 15 which indicated Resident #1 was cognitively intact, and required extensive assistance from two persons for his ADLs. Record review of Resident #1's quarterly MDS dated [DATE] indicated the type of assessment was a code 10: Discharge Assessment - return not anticipated. Resident #1 was sent to the hospital and facility did nto anticpate his return. Record review of Resident#1's Care Plan dated 07/26/23 revealed the potential for injury r/t Resident with Poly Microbial Infection (acute and chronic disease caused by various combinations of viruses, bacteria, fungi, and parasites) to wounds and refuses hospital care/transfer to hospital. The facility explained the risks to Resident regarding not going to the hospital for TX, and the need for IV antibiotics. Reisdent was also given an explanation about Assisted Living and Healthcare. Resident was provided with an explanation about the informed refusal form. Record review of Resident #1's Discharge Summary dated 08/04/23 indicated Resident #1 was transferred to the hospital for a sacral wound and signed by Resident #1's physician. Interview with the local Ombudsman on 02/20/24 at 1:50 PM revealed Resident #1 was transferred to the hospital and was not provided with a copy of the Bed Hold Policy. Resident #1 went to the hospital and was told that he had three days in which he could come back and still be accepted to the facility. Resident #1 went to the hospital on a Friday, and he returned on a Monday but was told he no longer had a bed available. Ombudsman said she assisted Resident #1 to appeal the discharge and the judge made the decision that the discharge should be reversed, and Resident #1 could then return to the facility. The Ombudsman said the judge signed the order on December 15th and Resident #1 still has not been returned to the facility. Interview with the facility SW on 02/21/24 at 2:57 PM revealed the SW said Resident #1 had a life-threatening infection and the doctor gave orders to send to the hospital. The SW said Resident #1 refused to go to the hospital and they were finally able to convince him to go. The SW said they explained about the bed hold and Resident #1 said he could not pay for the bed hold. The SW said Resident #1 was told if the hospital released him within three days, he would be able to return to his room. The SW said Resident #1 came back a day early, but he did not have any doctor's orders because he left the hospital AMA. Resident #1 was insisting the facility accept him back, but they told Resident #1 they could not admit him until they had doctor's orders. The doctor would not give orders because he left the hospital against medical advice. The Resident finally agreed to go back to the hospital but then he was transferred to a Long-Term Care Acute Hospital. Resident #1 was discharged from the facility. Resident #1 appealed the discharge and the judge decided that the discharge be reversed. In an interview on 02/21/24 at 3:38 PM Resident #1 said he was sent to the hospital and was told that he had three days before his bed would be taken. Resident #1 said he did not sign a bed hold or discharge paperwork. The facility did not tell him about the bed hold. Resident #1 said after discharged from the hospital he was transferred to a Long-Term Care Acute Hospital for two weeks. Resident #1 said he went to the hospital due to osteomyelitis and was in isolation. Resident #1 said he is not contagious and would only be able to infect someone if they touched his wound without gloves and the only ones that would touch him would be the nurses and they wore gloves. Resident #1 said he appealed the discharge, and the decision was that he could return to the facility. The facility kept saying they were full and did not have any beds available. Resident #1 said he still wanted to return because he was hoping to go upstairs to the ALF. Resident #1 said he had friends at the facility and would visit with them. Resident #1 said he hated being at the current facility and did not want to be there. Resident #1 said he spoke with the Administrator yesterday and he would be returning to the facility. In a telephone interview on 02/21/24 at 3:53 PM the former DON said he did remember Resident #1 but did not recall the incident when he went to the hospital. The former DON said he did not recall if Resident #1 was provided with discharge information or if he went to a Long-Term Care Acute Hospital. The former DON said he did recall that Resident #1 did not want to go to the hospital and that everyone was trying to convince Resident #1 that he needed to go. The DON said he could not provide any further information. In an interview on 02/21/24 at 4:12 PM the Administrator said the facility had not accepted Resident #1 because they did not have a long-term bed available, and they finally have one available. The Administrator said they have a Pending Admission List and Resident #1 was on it. The Administrator said they also had not accepted Resident #1 because he was on isolation, and he would not stay in his room. The Administrator said they were afraid that Resident #1 would not stay in his room and would infect other residents. The Administrator said they could provide a copy of the Pending Admission List. Record review of the Copy of the Pending Admission List dated 01/15/24 indicated Resident #1 was approved for admission. In an interview on 02/21/24 at 4:15 PM RN/Clinical Resource said Resident #1 was sent to the hospital due to a life-threatening infection. Resident #1 refused to do a bed hold. Resident went to the hospital and then went to a Specialty Acute Hospital. RN/Clinical Resource said the facility did not have an available bed for Resident #1 when he was ready to return. Record review of Fair Hearing - Medicaid Nursing Facility Residents - Discharge Order dated 12/15/2023, ordered by the Lead Hearing Officer Health and Human Services Commission revealed: In accordance with the decision, Facility is instructed to allow Appellant to remain in, or immediately be readmitted back to into its facility, if the Appellant and his representative so desire, and not transfer or discharge the Appellant from the facility. The Facility must report compliance with this order within 10 days from the date of this decision by completing and faxing the attached Health and Human Services Commission (HHSC) form H4807 (Action Taken on Hearing Decision) to the Hearings Officer. Facility is not precluded from issuing a new 30-day notice of discharge meeting program guidelines in the future. Record review of facility's Policy for Criteria for Transfer and discharge date d November 2016 and revised/reviewed in December 2023 indicated: It is the policy of this Facility that each resident will remain in the Facility, and not be transferred or discharged unless the discharge or transfer is appropriate as per the existing criteria. When the Facility transfers or discharges a resident, the Facility shall ensure the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. Procedure: 1. The facility shall permit each resident to remain in the Facility, and not transfer or discharge the resident from the Facility unless: i. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the Facility. ii. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the Facility. iii. The safety of individuals in the Facility is endangered to the clinical or behavioral status of the resident. 2. If the resident and/or their representative) exercises their right to appeal the transfer or discharge notice, the Facility shall not transfer or discharge resident while the appeal is pending, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the Facility. The Facility will document the danger that failure to transfer, or discharge would pose. Record review of Admissions from 12/15/23 to 02/20/24 revealed there were 82 residents admitted from Acute care hospital, five residents admitted from home, three admitted from Long Term Care Acute Hospital, and two residents were transferred from another skilled nursing facility.